1. Best Practices Guide
Provided by HUB International
December 2013
Preventing Workplace Violence
in Healthcare Facilities

2. Preventing Workplace Violence in Healthcare Facilities 3
Consider these situations
 An Emergency Room nurse at a busy hospital is assaulted by a
patient under the influence of drugs or alcohol.
 A staff member in the hospital’s Oncology Unit is verbally abused
by a dying patient’s family member who is emotional and angry.
 An employee in a physician’s practice is threatened by her
estranged husband who enters the doctor’s reception area
despite having a restraining order filed against him.
Not a good start to the day for any hospital risk
manager.
All of the above represent examples of work-
place violence that take place all too frequently
within healthcare organizations. Violent acts in
the workplace can involve patients, doctors,
employees, visitors and trespassers. Your
organization must maintain a zero tolerance
policy toward any and all acts of aggression
in the workplace. Doing so requires support
from senior leadership, training to develop the
proper skill set and successful implementation
of a violence prevention program.
Workplace violence is defined by NIOSH (Na-
tional Institute of Occupational Safety & Health)
as “violent acts (including physical assaults and
threats of assaults) directed toward persons at
work or on duty.” This definition includes acts
of terrorism as demonstrated by the Sep-
tember 11, 2001 attacks that resulted in the
deaths of 2,886 workers in the states of New
York, Pennsylvania and Virginia. Of course not
all workplaces are cut from the same cloth, and
security risks and threats of violence will vary
from facility to facility. Identifying your organi-
zation’s risk levels is the first step in guiding the
development of a violence protection program.
Defining violence as it pertains to your facility is
an important variable in this process. NIOSH’s
definition is often sufficient, although some
organizations may want to consider expand-
ing the definition to include verbal abuse. This
addition may increase awareness and reporting
of violent acts.
Problem Scope
The risk factors that drive workplace violence
are broad in scope. Aggression and violence
can come from many sources. NIOSH has sep-
arated traditional types of workplace violence
into four categories. Consider the following
when developing a definition of workplace vio-
lence for your internal prevention program:
Type I - Criminal Intent. In these cases, the
perpetrator usually has no legitimate relation-
ship with the practice or its employees. Acts
of terrorism fall into this category. The majority
of workplace homicides (85%) are the result
of Type I violence. The violence is incidental to
another crime such as robbery or mugging. If
your facility handles drugs or cash or is a target
for terrorism, there may be a higher risk of
criminal intent.
Type II - Customer/Client. The violent person
has a legitimate relationship with the prac-
tice as a patient, client or inmate and he/she
becomes violent in the course of receiving
treatment. The victims in this category are often
caregivers. This category accounts for the ma-
jority of nonfatal workplace violence incidents.
Type III - Worker-on-Worker. The perpetra-
tor is an employee or former employee who
attacks or threatens co-workers. All work-
places are at risk for this type of violence, but
those that do not conduct criminal background
checks as part of the hiring process experi-
ence greater risk. Those workplaces that have
recently undergone downsizing or reduction in
workforce are also at greater risk
Identifying your
organization’s risk
levels is the first
step in guiding the
development of a
violence protection
program.

3. Preventing Workplace Violence in Healthcare Facilities 4
Type IV-Personal Relationship. The perpetrator usually
has no relationship with the practice, but has personal ties
to the intended victim. This scenario includes victims of
domestic violence. This type of violence can occur in all
workplaces but is most difficult to prevent in facilities that
are accessible to the public during business hours, or have
only one location, making it difficult to transfer employees
being threatened.
According to the Joint Commission Sentinel Event Data-
base, since 2004, there have been significant increases
in reports of assault, rape and homicide that fall into this
category: 36 incidents reported in 2007, 41 in 2008 and
33 in 2009. Causal factors contributing to the events were
identified, and 62% of these cases exhibited notable prob-
lems in:
 Policy and procedure development and implemen-
tation
 Staff education needs and competency assessment
 Patient observation protocol, adequate assessment
tools and psychiatric assessment
The Bureau of Labor and Statistics published a 2010 US
Report in the Healthcare and Social Assistance category.
The report detailed 34 fatalities attributed to assault and
violent acts, with 8 occurring in the hospital setting, 3 in
home health care and 7 in physician offices.
We know that generally speaking, the numbers are actually
much higher, due to significant under-reporting of violence
in the healthcare setting. Clearly, there is a need for an
increase in awareness of workplace violence, and more
assistance with initiatives for program development or
improving current programs. Do you know if your current
security plan meets regulatory and state requirements? Are
you operating under the misconception that because you
are a small facility, it doesn’t matter or apply to you?
Regulatory Requirements
US Department of Labor Occupational Safety
and Health Act (OSHA)
OSHA published voluntary, generic safety and health
program guidelines for employers to use as a foundation
for their safety programs which would include workplace
violence prevention. However, OSHA has a “General Duty
Clause” that requires employers to provide a safe and
healthy workplace for all employees covered by the OSH
Act. Employers who do not take responsible steps to
prevent or abate a recognized violence hazard in the work-
place can be cited.
Case in Point – In the News. In June 2013, the Conway
Daily Sun reported Lakeview Neuro Rehabilitation Center in
New Hampshire was contesting a citation issued by OSHA,
which claimed the center exposed employees “to physical
abuse while working with aggressive patients by them-
selves.” An inspection was conducted in response to a
complaint lodged by a former employee, who left because
she felt her safety was in jeopardy due to a small number
of dangerous clients admitted to the facility. Based on injury
reports, programs and policies, and employee interviews,
OSHA concluded Lakeview was in violation of a section of
the OSH Act called the “General Duty Clause.” OSHA felt
the “employer had not developed and/or implemented ade-
quate measures to protect its employees from this hazard.”
(For the full story, go to http://bit.ly/KCTISQ)
Do you know
if your current
security plan
meets regulatory
and state
requirements?

4. Preventing Workplace Violence in Healthcare Facilities 5
Case in Point – In the News. In Lakeland,
Florida, also in June 2013, The Ledger reported
a home health worker was stabbed to death by a
client she was scheduled to visit. Stephanie Ross,
the service coordinator, had visited the client on
three previous occasions, and had filed case notes
indicating the client made her uncomfortable. She
suggested she be accompanied on future vis-
its. OSHA stated, “A serious safety violation has
been cited for exposing employees to incidents of
violent behavior that resulted in death.” A second
violation was issued because the company failed
to report the workplace fatality. Apparently, the
client had an extensive criminal record including a
14-year prison stint for aggravated assault with a
deadly weapon. The health management compa-
ny who employed Stephanie claimed they were
not aware of the client’s criminal background.
Should a home healthcare company’s safety
protocol include background checks on clients
who will receive home visits from employees, most
often unaccompanied? (For the full story of this
tragic event, go to http://bit.ly/LBtCAz)
Centers for Medicare and Medicaid (CMS).
CMS’ Condition of Participation (CoP) manual cov-
ers privacy and safety under the Patient’s Rights
section (§482.13(C)2,3), which states the patient
has the right to receive care in a safe setting and
the patient has the right to be free from all forms
of abuse or harassment. CMS leaves the imple-
mentation details to individual hospital policy and
procedure, expecting that organizations will follow
their policies as developed, and in accordance
with state law.
Although Restraint and Seclusion are beyond
the scope of this article, do pay attention to the
standards in this area when considering your vio-
lence prevention program. “Taking down” patients
as may be necessary when one is in jeopardy of
harming themselves or others. Refer to CMS Reg-
ulation §482.13(e).
The Joint Commission. If your facility is accred-
ited by the Joint Commission, there are several
standards surrounding safety and security that
pertain to a violence prevention program. The
Environment of Care (EOC) standards require
healthcare facilities address and maintain a written
plan describing how an institution provides for the
security of patients, staff and visitors. The EOC
standards also require facilities to conduct risk
assessments to determine the potential for vio-
lence, provide strategies for preventing instances
of violence, and establish a response plan that is
enacted when an incident occurs (EC 01.01.01),
(EC 02.01.01).
There are other Joint
Commission standards
that refer to safety and
security from other
manuals such as the
Rights and Respon-
sibilities Standard (RI
01.06.03), which pro-
vides for the patient’s
right to be free from neglect, exploitation and
verbal, mental, physical and sexual abuse. Also
consider the Emergency Management manual,
which has standards regarding facility security and
safety management during an emergency as well
as staff coordination during a crisis, as part of the
overall required Emergency Management Operat-
ing Plan (EM 02.02.05), (EM 02.02.07). Additional-
ly, there are Human Resource standards pertaining
to required staff orientation (HR 01.04.01).
The regulations and standards identified are not an
all-inclusive list. Refer to facility logistics accord-
ingly, as the size and type of healthcare facility in
operation comes with its own particular require-
ments, both state and federal.
First Steps – Strategy Development
Developing a strategy for violence prevention
needs to be assessed with your particular facility
and its unique challenges in mind. If you are a
large healthcare system with multiple buildings
and hundreds or thousands of employees, then an
extensive assessment would be reasonable and
appropriate. You will most likely have a dedicated
security department staffed with guards, extensive
video surveillance, a consistent law enforcement
presence and overhead code calls that elicit
response from a variety of units. There is a great
deal more to evaluate in these situations. If yours
is a smaller system, such as a medical practice or
an ambulatory center, large scale access to as-
sistance may not be available. Start by gathering
baseline data. Perform an assessment to identify
high risk areas. This doesn’t have to be a labor
intensive endeavor.
The Environment of Care (EOC)
standards require healthcare
facilities address and maintain a
written plan describing how an
institution provides for security.

5. Preventing Workplace Violence in Healthcare Facilities 6
The assessment process for a small facility may be brief and to the point - a survey or ques-
tionnaire to determine the level of security risk the office faces. See Attachment 1, Workplace
Violence Checklist. This is one of many tools available from the OSHA.gov website. It’s a
great resource for a small facility to begin evaluating potential risk. The checklist takes only a
moment to complete. Initiating a conversation with staff about violence concerns is integral
to the program development as well. Asking staff members to complete the checklist, then
discussing the results would be of great value to plan formation. There are added benefits
to including staff in the process and security. By making them stakeholders in development,
you’ll also promote morale. Everyone wants to feel safe in the workplace. Do not deny the
people who keep the practice running the opportunity to contribute to creating a workplace
that promotes safety and security for all.
Compile the responses from the checklist. All “true” answers are indicators of risk. Simply
take those responses and develop an action plan based on these indicators, then execute a
plan by implementing new procedures.
For example, a small physician practice completes the checklist and finds there are twelve
“true” responses. Some questions are similar in nature and may be combined as one ac-
tionable item on the plan, if appropriate. The first item on the action plan would correlate to
the first “true” response. Let’s say this practice answered “false” to question one because,
though they have experienced violent behavior in the workplace, it’s not a frequent occur-
rence. They answered “true” to question two, that violence has occurred on the premises.
Also question three is similar and they answered “true” that clients/coworkers have assault-
ed or verbally abused employees. Question nine is also similar and asks if employees or
staff members have been assaulted, so the practice answered “true” here as well. All three
of these responses can be listed under one action item for the purposes of developing a
plan. Also there are similar questions pertaining to training of staff that can be combined into
one action item. So let’s say the plan boils down to the following; staff have been assaulted
(verbally) by patients, they have not been properly trained on crisis intervention and they do
not have an alarm system available equipped with panic buttons, which would offer a greater
sense of security.
Initiating a
conversation
with staff
about violence
concerns is
integral to
program
development.
Perform an
assessment to
identify high -
risk areas.

6. Preventing Workplace Violence in Healthcare Facilities 7
The action plan may identify these issues and
improvements may be made such as:
 Installing panic buttons at the front desk
and in one or more treatment rooms;
 Conducting intervention training for staff so
they learn the skills and strategies needed
to defuse hostile behavior from patients or
fellow employees;
 Limiting access to clients or patients who
have a business/medical reason to be on
premises;
 Instituting a buddy system when the prac-
tice closes for the day so no one leaves
alone.
Also, developing a relationship with local law en-
forcement to introduce the practice while advising
them of concerns you may have is crucial. Invite
them to come to the practice to help you assess
the level of risk and offer suggestions. Perhaps
they would be willing to offer staff some training on
crisis intervention. Welcome them to frequent the
practice, stop in for a cup of coffee and make their
presence known to the public.
Keep in mind that you may not own the premises
and your ability to maintain a highly secure building
may be limited to the property owner’s willingness
to comply. Surveillance cameras may not be feasi-
ble but proper lighting in designated parking lots is
certainly a reasonable request.
These are all easy changes with low financial
investment that clearly promote safety and security
of staff and minimize the practice’s exposure to
workplace violence. OSHA does not require that
small facilities like an office practice maintain a
written safety program, however you are expect-
ed to be able to articulate it. Develop a policy
on workplace violence prevention or safety and
security, and place it in the practice operations
manual or employee handbook. By adopting these
practices, there is a written policy which may be
short and to the point, available to staff for training
purposes during new employee orientation and
also if requested by an OSHA official. Ensure
that during the hiring process office management
or human resources runs criminal background
checks on all prospective job candidates. Docu-
ment all processes and incorporate into your vio-
lence prevention program or Environment of Care
operations plan. Mark the calendar and in a year’s
time, reassess the risk by conducting an annual
evaluation, measuring the progress of your plan.
Share these reports with staff so they know what
measures are being taken to assure their safety.
Reporting an Event
Should an incident occur, it
must be reported immedi-
ately to a supervisor, office
manager, security person-
nel and risk management.
Include as many facts and
details as possible when the
incident is fresh in order to
provide the most thorough
account. A full investigation
of the claim is then conduct-
ed with staff/patient interviews, pictures or video
surveillance evidence, and any other evidence
relevant to the incident, such as weapons or
contraband. Involving the local authorities may
be necessary, and a police report will need to be
completed in these cases. Make sure the proper
reporting of an event is also part of the program/
policy expectations. There should be no hesitation
in filing charges as appropriate against employ-
ees or patients, and could result in a restraining
order or assault charges. If you promote a zero
tolerance policy toward workplace violence, then
support the filing of charges as necessary. Make
sure there are consequences to acts of violence.
You set the precedent.
Summary
Protecting the employees, patients, and visitors of
a practice is an important duty. Take the role seri-
ously. Leadership has responsibilities to regulatory
bodies supporting the facility as well as the legal
system, protecting all from criminal activity. Re-
gardless of the relationship category of the violent
act-- employee to employee, employee to patient,
patient to employee or trespasser to employee
or patient-- as the leader of the system, you are
expected to provide a safe environment for all.
Make sure there are
consequences to acts
of violence. You set the
precedent.

7. Preventing Workplace Violence in Healthcare Facilities 8
Remember the strategy:
 Identify high-risk areas/perform annual assessments (if appropriate, initiate a
safety team)
 Develop policies and procedures to protect all parties – define “violence”
 Use developed criteria, including criminal background checks in the hiring pro-
cess
 Train appropriate staff in crisis intervention to minimize likelihood of violent inci-
dents
Start by finding out what safeguards your organization is required to have in place. The
Department of Labor’s Occupational Safety & Health Administration (OSHA.gov) offers
guidance for workplace violence program needs. Refer to regulation 3148-01R and use
as a baseline for developing your own program. Be mindful of implementing portions
of the OSHA program that are required. There may be specific guidelines mandated
by your state that must also be part of your implementation strategy, and OSHA offers
some assistance with links to state specific guidelines. The OSHA.gov site is very easy
to navigate and offers a wealth of valuable information. It is a critical resource for pro-
gram development.
Don’t overlook the Centers for Medicare & Medicaid Condition of Participation 42CFR
§482.13 federal regulation, requiring healthcare facilities provide a safe setting for pa-
tients to ensure they are not subject to any form of abuse or harassment. Additionally,
if you are accredited by The Joint Commission, the Environment of Care standard for
hospitals (same for CAHs), EC 02.01 requires that hospitals identify safety and security
risks associated with the environment of care that could affect patients, staff, and other
people visiting the hospital’s facilities. If you are not accredited, these are certainly some
best practice guidelines available to anyone looking to develop a safe environment
program offering.
Risk Management’s Role
It should go without saying that you want your facility to be safe and threat-free for
patients, visitors and staff. So why get Risk Management involved? Consider a violent
incident that results in a criminal charge and a claim against your organization. Assure
staff this is a reportable occurrence and encourage the use of the incident reporting
system. Trending analysis of these events is important to reassessing plans to address
areas that may require an increased security presence. It’s imperative that Risk Manage-
ment collaborate with the security team, and be a member of any safety committee that
will review activities performed by the facility. Finally, develop a relationship with local law
enforcement. If you are without a security department, a good rapport with the police
unit in your area could be the difference between a potential and an actual event. Reach
out to other area facilities and ask how they are managing safety practices, especially
if they are also without a dedicated security department, and utilize ad hoc teams to
execute safety protocols. Together you can create a standard based on best practices.
Implementing a violence prevention program should not be intimidating or daunting. For
help with program or policy development for your particular facility, please contact your
HUB International broker who can introduce you to a HUB Risk Consultant.
Use developed
criteria, including
criminal background
checks in the hiring
process.

8. Preventing Workplace Violence in Healthcare Facilities: Workplace Violence Incident Reporting Form 9
Date Reported: _____________________________
Name of Person Making Report: _____________________________________________________Telephone Number: ___________________________
If anonymous, indicate method of notification:  Telephone call  Written document  Other; specify: ________________________________
Name/Location of the affected Work Unit/ Department: ______________________________________________________________________________
Name of Alleged Threat Maker/Perpetrator: ________________________________________________________________________________________
Relationship to the Work Unit/ Department:  Employee  Student  Visitor  Vendor  Contractor
Relationship to Victim/Potential Victim (if any): ______________________________________________________________________________________
Name of Victim/Potential Victim: _________________________________________________________________________________________________
Additional information or documents may be attached if necessary
When (date) and where (physical location) did alleged threat or act of violence occur? ____________________________________________________
______________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________
What events occurred immediately prior to the incident? _____________________________________________________________________________
______________________________________________________________________________________________________________________________
What was the specific language of the alleged threat? _______________________________________________________________________________
_____________________________________________________________________________________________________________________________
Provide specific details of the alleged threat or act of violence: ________________________________________________________________________
______________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________
Describe the conduct and appearance of the Threat Maker/Perpetrator (physically and emotionally): ________________________________________
______________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________
Name of Witnesses
1) _____________________________________________________________________________
2) _____________________________________________________________________________
3) _____________________________________________________________________________
Telephone Numbers
____________________________________________
____________________________________________
____________________________________________
What happened to the Threat Maker/Perpetrator after the incident? ___________________________________________________________________
______________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________
Names of supervisory staff involved and how they responded: ________________________________________________________________________
______________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________
Steps that have been taken to ensure the threat will not be carried out or act of violence repeated: _________________________________________
______________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________
Was local Law Enforcement notified?  Yes  No
If yes, what action was taken by Law Enforcement?  No action taken  Report written  Suspect escorted from property  Suspect arrested
Name of local Law Enforcement Agency: __________________________________________________________________________________________
Suggestions for preventing a similar incident in the future: ____________________________________________________________________________
______________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________
Report Prepared by: _____________________________________________________________ Date: ______________________________________
Job Title: ______________________________________________________________________ Phone: _____________________________________
Workplace Violence Incident Reporting Form

9. Preventing Workplace Violence in Healthcare Facilities: OSHA Workplace Violence Checklist 10
Following is an OSHA checklist that can help employers identify potential workplace violence issues.
This checklist helps identify present or potential workplace violence problems. Employers also may be aware of other serious
hazards not listed here.
Designated competent and responsible observers can readily make periodic inspections to identify and evaluate workplace secu-
rity hazards and threats of workplace violence. These inspections should be scheduled on a regular basis; when new, previously
unidentified security hazards are recognized; when occupational deaths, injuries, or threats of injury occur; when a safety, health
and security program is established; and whenever workplace security conditions warrant an inspection.
Periodic inspections for security hazards include identifying and evaluating potential workplace security hazards and changes in
employee work practices which may lead to compromising security. Please use the following checklist to identify and evaluate
workplace security hazards. TRUE notations indicate a potential risk for serious security hazards.
Workplace Violence Checklist*
__T__F This industry frequently confronts violent behavior and
assaults of staff.
__T__F Violence has occurred on the premises or in conduct-
ing business.
__T__F Customers, clients, or coworkers assault, threaten,
yell, push, or verbally abuse employees or use racial
or sexual remarks.
__T__F Employees are NOT required to report incidents or
threats of violence, regardless of injury or severity, to
employer.
__T__F Employees have NOT been trained by the employer
to recognize and handle threatening, aggressive, or
violent behavior.
__T__F Violence is accepted as “part of the job” by some
managers, supervisors, and/or employees.
__T__F Access and freedom of movement within the work-
place are NOT restricted to those persons who have
a legitimate reason for being there.
__T__F The workplace security system is inadequate-i.e.,
door locks malfunction, windows are not secure, and
there are no physical barriers or containment systems.
__T__F Employees or staff members have been assaulted,
threatened, or verbally abused by clients and patients.
__T__F Medical and counseling services have NOT been
offered to employees who have been assaulted.
__T__F Alarm systems such as panic alarm buttons, silent
alarms, or personal electronic alarm systems are NOT
being used for prompt security assistance.
__T__F There is no regular training provided on correct re-
sponse to alarm sounding.
__T__F Alarm systems are NOT tested on a monthly basis to
assure correct function.
__T__F Security guards are NOT employed at the workplace.
__T__F Closed circuit cameras and mirrors are NOT used to
monitor dangerous areas.
__T__F Metal detectors are NOT available or NOT used in the
facility.
__T__F Employees have NOT been trained to recognize and
control hostile and escalating aggressive behaviors,
and to manage assaultive behavior.
__T__F Employees CANNOT adjust work schedules to use
the “Buddy system” for visits to clients in areas where
they feel threatened.
__T__F Cellular phones or other communication devices are
NOT made available to field staff to enable them to
request aid.
__T__F Vehicles are NOT maintained on a regular basis to
ensure reliability and safety.
__T__F Employees work where assistance is NOT quickly
available.
*This form was taken from: Guidelines for Preventing Workplace
Violence for Health Care and Social Service Workers.
OSHA Publication 3148, (1996).

10. Preventing Workplace Violence in Healthcare Facilities: Attachment A 11
Part I
Part I of the facility assessment consists of a floor by floor,
office by office inspection of the facility and grounds,
making note of the following:
 Hidden doors, closets, hallways, driveways, etc.
 Isolated work areas
 Hours of operation which may create an isolated work
area
 Adequate, available lighting
 Unrestricted areas (where unauthorized individuals
can gain access)
 Work areas where staff work alone
 Appropriate locks on doors and windows
 Appropriate, accessible alarm systems (fire, duress)
 Adequate, clearly identified escape routes
 Employee concerns in the inspected area
 Overall security of the area
 Other specific work tasks (lists):
 Recommendations based on the inspection findings
may include, but are not limited to, the installation or
implementation of:
 ID Badges
 Security/surveillance cameras
 Card (bar coded) access systems
 Metal detectors
 Security staffing
 Bullet proof glass/partitions/barricades
 Escort system or buddy system
Part II
Part II of the facility assessment consists of a thorough
review of the workplace, focusing on providing a non-
threatening, user friendly environment. Providing such an
atmosphere can be accomplished through the following:
 Bright (natural lighting when possible), clean,
comfortable, cheerful waiting areas and office space
 No cramped, confined waiting areas and office space
 Distractions for patients and visitors, such as music,
magazines, video games, TV, aquariums, plants,
refreshments, waiting time updates.
 Soft, natural colors
 Art work
 Comfortable furniture
 Carpeting (reduces background noise)
 Access to public telephones and bathrooms
 Flexibility (be prepared to address a person’s
immediate needs)
 Access to a patient (human) relations representative
The following checklists and guidelines can be utilized in the implementation and maintenance of a workplace
violence prevention program.
Physical Security/Threat Assessment Checklist

11. Preventing Workplace Violence in Healthcare Facilities: Attachment A 12
Recommendations: Note physical conditions and policies
that need to be improved to promote facility security
Responsible Party Corrective Action Date
Completed By: Date:

12. Preventing Workplace Violence in Healthcare Facilities: Attachment B 13
Control Guidelines and Strategies
Review the following control guidelines and strategies to determine which are applicable
General Control Guidelines – Administrative controls
 Zero tolerance policy regarding violence requiring staff to report any and all incidents of violence or suspected violence or threat
and suspicious event.
 Use effective supervisory training
 Provide debriefing all employees
 Standardized uniforms for employees or mandatory ID wearing
 Provide training for staff in recognizing and managing hostile and assaultive behavior.
 Provide adequate staffing even during night shifts. Increase staffing in areas where assaults by patients are likely (e.g., Emer-
gency Department). 24-hour coverage for doors, reception and access ways. At least two employees at one time. Always stay
in ED.
 Increase worker safety during arrival and departure by encouraging carpools and by providing security escorts and shuttle
service to and from parking lots and public transportation.
 Ensure accurate reporting of all violent behavior.
 Establish liaison with police authorities and contact them when indicated.
 Obtain previous records of patients to learn of any past violent behaviors.
 Establish a system to chart or track and evaluate possible assaultive behaviors, including a way to pass on information from
one shift to another.
Physical Control Strategies
The following general physical control strategies will help minimize the occurrence and effects of workplace violence or
security issues:
 Assess any plans for new construction or physical changes to the facility or workplace to eliminate or reduce security hazards
 Control access to building
 Enhance outside visibility of entrances
 Enhance interior and exterior lighting. Provide better visibility and good lighting, especially in areas of high risk such as the
pharmacy area, or in isolated treatment areas. Place curved mirrors at hallway intersections or concealed areas.
 Erect barriers to prevent vehicles being driven in or near sensitive areas such as entrances, generators, air intakes, etc.
 Assess traffic flow and control measures in the event of a security threat or other emergency. Assure access to the site by
responding emergency personnel. Identify resources to help control traffic from local authorities.
 Implement safety measures to deter handguns inside facility; for example using metal detectors.
 Develop emergency signaling, alarms, and monitoring systems. This may include panic buttons, beepers, surveillance camer-
as, alarm systems, metal detectors, two-way mirrors, card-key access systems and security guards.
 Design waiting areas to accommodate and assist visitors and patients who may have a delay in service.
 Provide employee “safe rooms” for use during emergencies. Designate areas where employees can lock doors with phone.
 Keep automobiles well-maintained if they are used in the field. Lock automobiles at all times.
 Design the triage area and other public areas to minimize the risk of assault.
 Provide staff restrooms and emergency exits.
 Install enclosed nurses’ stations.
 Install deep service counters or bullet-resistant and shatterproof glass enclosures in reception areas.
 Arrange furniture and other objects to minimize their use as weapons.
 Use drop safes to minimize cash on hand.
 Ensure a safer room for a potential violent patient.
 Arrange furniture to prevent entrapment of staff, furniture should be minimal, lightweight, without sharp corners, and/or affixed
to the floor.

13. Preventing Workplace Violence in Healthcare Facilities: Attachment B 14
 Minimize clutter and ensure nothing is available on countertops to throw at workers or use as weapons.
 Provide a secondary door for escape in case main door is blocked by patient.
 Closed Circuit TV: Statement of policy about covert and visible camera use is communicated to visitors and staff. Cameras are
used in high risk areas. Recordings are maintained and can be sustained in the event of a power failure. Surveillance cameras
can be viewed from command center, security desk, and alternative site such as remote computer.
 All electronic security devices such as TV’s, recording equipment, panic alarms, locks, lighting systems, and phone systems
must be tested on a regular basis.
 Access to metal detectors and training how to use devices. Policy listing prohibited items and search procedures.
 Use of ACCESS CONTROL biometrics (finger printing) for sensitive areas such as computer access or record storage.
 Controlling access and egress from sensitive areas
Administrative Control Strategies
Administrative and work practice controls affect the way staff perform jobs or tasks. Changes in work practices and admin-
istrative procedures can help prevent violent incidents. Some control strategies include:
 Establish liaison with local police and state prosecutors. Report all incidents of violence. Give police physical layouts of facilities
to expedite investigations.
 Require employees to report all assaults or threats to a supervisor or manager (for example, through a confidential interview).
Keep log books and reports of such incidents to help determine any necessary actions to prevent recurrences.
 Advise employees of company procedures for requesting police assistance or filing charges when assaulted and help them do
so, if necessary.
 Require employees to display identification badges at all times, preferably without last names, to readily verify employment.
Retrieve badges of terminated employees or render obsolete (for card access systems). Assure that Human Resources notifies
security officer on daily basis of all terminations and/or resignations. Require monetary deposit for an employee’s ID at time of
hire and refund only upon the return of the ID and other materials. Charge fee or penalty for lost ID cards. Terminate access to
phones, email, patient information upon termination.
 Provide security escorts to the parking lots at night.
 Use properly trained security officers to deal with aggressive behavior.
 Ensure that adequate and properly trained staff is available to restrain patients or patients, if necessary.
 Provide sensitive and timely information to people waiting in line or in waiting rooms. Adopt measures to decrease waiting time.
 Ensure that adequate and qualified staff is available at all times. The times of greatest risk occur during patient transfers, emer-
gency responses, at mealtimes and at night. Areas with the greatest risk include admission units and crisis or acute care units.
 Control access to facilities other than waiting rooms, particularly drug storage or pharmacy areas.
 Prohibit employees from working alone in emergency areas or walk-in clinics, particularly at night or when assistance is unavail-
able. Do not allow employees to enter seclusion rooms alone.
 Establish policies and procedures for secured areas and emergency evacuations.
 Determine the behavioral history of new and transferred patients to learn about any past violent or assaultive behaviors.
Establish a system—such as chart tags, log books or verbal census reports—to identify patients and patients with assaultive
behavior problems. Keep in mind patient confidentiality and worker safety issues. Update as needed.
 Treat and interview aggressive or agitated patients in relatively open areas that still maintain privacy and confidentiality (such as
rooms with removable partitions).
 Prepare contingency plans to treat patients who are “acting out” or making verbal or physical attacks or threats. Consider
using certified employee assistance professionals or in-house social service or occupational health service staff to help diffuse
patient or patient anger.
 Ensure that nurses and physicians are not alone when performing intimate physical examinations of patients.
 Discourage employees from wearing necklaces or chains to help prevent possible strangulation in confrontational situations.
 Discourage employees from carrying keys, pens or other items that could be used as weapons.
 Provide staff members with security escorts to parking areas in evening or late hours. Ensure that parking areas are highly
visible, well lit and safely accessible to the building.
 Advise staff to exercise extra care in elevators, stairwells and unfamiliar residences; leave the premises immediately if there is a
hazardous situation; or request police escort if needed.

14. Preventing Workplace Violence in Healthcare Facilities: Attachment B 15
 Take additional security precautions if necessary if an external threat is discovered such as additional security positions, bag
checks, wanding for weapons, etc.
 Provide training for security staff including counter-terrorism that encompasses the threat assessment, National threat levels
and awareness to weapons of mass destruction.
 Policies that govern how security personnel deal with weapons, physical force, and personal searches.
 Policies to accommodate law enforcement personnel who are on premises guarding prisoners or protecting a crime scene.
 Security personnel demonstrate competency in the site security requirements.
 Employee training for bomb threat situations.
 Policy for issuance of identification cards for staff and volunteers. ID’s worn at all times. ID does not show address of facility
but has unique identifiers. ID has photo, department, name and credentials. ID cards are color-coded or distinctive for sensitive
areas such as ED, Pharmacy, Nursery.
 Policy for disciplinary action for employees who fail to show/possess ID card. Progressive disciplinary action for repeated
offenses. Supervisors are accountable in enforcing this policy.
 Policy addressing issuance and termination of ID cards and access cards that addresses: handling and storage of cards,
authorization for creating cards and managing passwords, procedures for replacing lost cards and keys. Penalty for lost key
cards and ID cards.
 Disciplinary action for vendors and volunteers who fail to wear or properly handle ID cards similar to above.
 Vendors and contractors report to main lobby or other designated area to obtain a pass or ID badge. Badge must be distinct
from those provided to visitors. Vendors that visit on regular basis wear a badge with photograph. Badges for routine vendors
may vary based on frequency or access allowed at the facility.
 Deliveries must be made during normal business hours. Food, flowers, and personal items must be delivered to the lobby
checkpoint and will be delivered to patient areas by authorized personnel or cleared visitors. Loading areas should be moni-
tored by camera and/or secured gate.
 Packages including regular mail, FEDEX/UPS, etc.. to be delivered to (designated delivery area). Policy for searching suspi-
cious mail or packaging including packaging that is damaged, leaking substances, mailed without return address, addressed
to unknown personnel. If unknown substance is found employees should wash hands immediately, clear the area, and contact
police. See United States Postal Service Guidelines for suspicious mail guidelines.
 Contractors: Security or authorized personnel should be contacted at least 24 hours in advance if contractors are working on
site.
 Visitors: Visitors are required to obtain passes before proceeding to other areas of facility. Policy regarding identification of
visitors that addresses consequences for violating access restrictions. Limit the number of visitors in emergency department
and other patient areas. Visitors are escorted by staff to destination unless cleared with a pass for designated area. Policy for
unauthorized visitors or intruders to be photographed to assist in future prosecution should it be needed at a later date and
arrested.
 Prohibit use of bathrooms, break rooms, and locker areas for non-authorized visitors and vendors.
 Exit and entrance doors are equipped with electronic alert system if compromised by unauthorized entrance or propping open.
 Procedure for ensuring the integrity of an electronic access control system, including card readers and closed circuit tv sys-
tems in the event of a power failure such as additional security staffing, personnel checking and verifying access control points,
and power backup.
 Post signs on the exterior of the facility informing persons of visiting hours, access to the facility, trespassing and potential bag
searches
 Any group or individual causing a disturbance without violence will be escorted from the building. If necessary, photographed
and an incident report completed to document the case, including all parties involved in or to whom any aggression was
intended for.
 The police should be contacted in cases where groups or individuals refuse to leave or are deemed to be aggressive with the
potential to harm others.

15. HUB International Limited
Hub International Limited is a leading global insurance brokerage that provides property and casualty, life and
health, employee benefits, investment and risk management products and services through offices located in the
United States, Canada and Latin America.
HUB International Risk Services
This dedicated practice within HUB International offers a wide range of specialty services to assist clients in
identifying risks, reducing hazard exposures, and addressing claims issues. The HUB Risk Services Team comprises
board-certified and degreed claims, safety, security, property, and environmental professionals with an average of
over 20 years experience. These specialists can be leveraged to supplement a client’s internal capabilities or target
specific issues. Results are achieved through a reduction in clients’ Total Cost of Risk (TCOR).
This information is provided for general information purposes only. HUB International makes no warranties, express,
implied or statutory, as to the adequacy, timeliness, completeness or accuracy of information in this document.
This document does not constitute advice and does not create a broker-client relationship. Please consult a Hub
International advisor about your specific needs before taking any action. Statements concerning legal matters
should be understood to be general observations and should not be relied upon as legal advice, which we are not
authorized to provide.
www.hubinternational.com