The recent fatal shooting of a nursing assistant at Philadelphia-based Thomas Jefferson University Hospital was a stark reminder that the COVID-19 pandemic is not the healthcare industry's sole challenge
"There is a very fundamental problem in U.S. healthcare that very few people speak about … and that's violence against healthcare workers," Tom Mihaljevic, Cleveland Clinic's president and CEO, told NPR in 2019. "Daily — literally, daily, we are exposed to violent outbursts, in particular in emergency rooms." This, coming from one of U.S. News & World Report's top-ranked hospitals — an indicator that no hospital is spared from this endemic-level issue.
About 75 percent of nearly 25,000 workplace assaults that are reported annually in the U.S. happen in healthcare settings, according to the Occupational Safety and Health Administration. The problem is most pronounced in the emergency department, with nearly half of emergency physicians reporting they've been physically assaulted at work, and 71 percent having personally witnessed others being assaulted on the job, according to 2018 survey findings from the American College of Emergency Physicians.
While the general public might not realize the extent of the issue, it's widely recognized and discussed within the industry. And yet, the problem persists.
Why violence persists
Currently, hospitals are not federally required to have workplace violence prevention plans, the Milwaukee Journal Sentinel reports.But the number of hospitals with such plans grew from 27 percent in 2016 to nearly 56 percent in 2018, according to an American Hospital Association report.
In April the U.S. House of Representatives passed the Workplace Violence Prevention for Health Care and Social Service Workers Act. The legislation would require healthcare and social service industry employers to develop and implement a comprehensive workplace violence prevention plan. Under the legislation, which has not passed the Senate, employers would be required to train workers at risk of violence exposure and submit an annual summary of violent incidents to federal officials.
Meanwhile, beginning in 2022, Joint Commission-accredited hospitals will need to abide by new workplace violence prevention requirements.
Part of why violence against healthcare workers persists at the level it does relates to how security costs are perceived by those in charge of budgets. Generally, these costs are regarded as investments required to meet regulatory requirements.
"They don't look at it as a revenue-producing department, so it's generally not an investment kind of thing," said Lauris Freidenfelds, a security consultant who specializes in the healthcare sector. He is the senior project manager at Telgian Engineering & Consulting and previously was director of security and emergency preparedness at Chicago-based Rush University Medical Center.
"They tend to look at security budgets and never really equate it to things that can help prevent violence," Mr. Freidenfelds told Becker's.
Instead, what drives security spending are codes, guidelines and compliance. However, given the historical lack of federal requirements on hospital workplace safety plans, there likely hasn't been much motivation to go the extra mile with these measures.
With the Joint Commission's upcoming workplace safety requirements, however, "I think you'll find that hospitals will be forced to go ahead and spend the money to make those kind of things happen," Mr. Friedenfelds said.
Still, "regulation does not equal protection," said Gordon Snow, Cleveland Clinic's chief security officer and former assistant director of the FBI's cybersecurity division. "You need to exceed those regulatory watermarks and really get to the place where you can provide protection to everybody," Mr. Snow told Becker's.
From 2009 to 2018, hospital CEO compensation grew 53 percent, according to research from the Economic Policy Institute cited by the Milwaukee Journal Sentinel. At the same time, security budgets across California — the only state that requires disclosure of security spending — remained flat, the Sentinel's analysis of hospital financial statements found.
Security measures also tend to remain stagnant because there's an understood sentiment that many front-line healthcare workers will continue to show up, despite violent incidents.
"Nurses, like teachers and other front-line workers, see their job as a calling," Emily Twarog, PhD, a professor at the University of Illinois at Urbana-Champaign who has studied workplace violence against nurses, told the Sentinel. "The top-level management, the folks who are deciding what the budget is going to be look like, knows that. They know that nurses are going to keep showing up."
Violence against healthcare workers is also underreported because they're often discouraged from reporting incidents or pressing charges, advocates say.
"Hospital's don't want to deal with it," Gerard Brogan, director of nursing practice at National Nurses United, told WebMD. "They don't want their hospital to get a reputation as being a difficult place to work."
Moving the needle on violence prevention
First, understand threats can never be reduced to zero, no matter how much is spent on preventive measures, Mr. Snow said.
"Risk equals threat times vulnerability," he said. "We know we'll never reduce the threat to zero. So there will always be some risk, but we can modulate that vulnerability through mitigation."
Advanced security measures can be pricey, and while they're not a revenue-producing investment, the implications of not beefing up mitigation can be much worse than the cost.
"It's always a cost to the organization," Mr. Snow said. "But if you look at it from the perspective of our leaders here, it's a cost not to provide security."
With this in mind, Cleveland Clinic has implemented a comprehensive, six-point workplace safety plan over the last few years that involves police presence in every emergency department, enhanced weapons screening, updated panic alarms and more. After the system implemented walk-through metal detectors and required ED patients and visitors to be screened with a hand-held wand, it confiscated more than 30,000 weapons from its Northeast Ohio facilities in 2018.
While not all hospitals have the resources to execute this suite of preventive efforts, there are cost-effective strategies to prioritize security investments.
First, routine risk-based assessments are important to identify where more security may be most beneficial.
"We do a constant reassessment of risk," Mr. Snow said. "We're assessing all the risks in our area and across the nation as it relates to healthcare," which helps pinpoint an organization's specific needs, he said.
At Cleveland Clinic, assessment occurs daily. Then, it looks at the data to make decisions about how security may be improved.
"We might decide to start a pilot on something. That's how we put the magnetometers in place," Mr. Snow said.
However, that doesn't mean the health system is done.
"We're moving right onto the next piece," Mr. Snow said.
If an incident occurs, the Cleveland Clinic team will analyze the days and hours leading up to the event to identify how it happened.
"Then we can adjust to make sure that doesn't happen again," Mr. Snow said.
With the magnetometers, the pilot turned into implementation because the data, along with feedback from the community, caregivers and employees, showed they were beneficial. When a pilot program has been approved, the information collected during that process makes it easier to get full authorization from leaders and implement permanently, Mr. Snow said.
Hospital leaders can sometimes be hesitant to adopt security measures such as metal detectors that may hinder the open and friendly environment they aim to create. But Cleveland Clinic's metal detector pilot demonstrated the benefits of having them by offering evidence in the form of the number of weapons confiscated and employee feedback.
Enhanced staff training is also a cost-effective investment hospitals should prioritize when it comes to security, Mr. Friedenfelds said.
In many situations, he said he's witnessed encounters with patients or visitors where a caregiver's lack of sensitivity training escalated the situation.
"The next thing you know, there's an argument or an outburst," Mr. Friedenfelds said. "I think training and sensitivity on how to handle situations and how to deescalate with people that are emotional … that's an area that can easily be identified as an opportunity for some investment."
It's usually simple to introduce since healthcare workers are used to training.
"In the healthcare world, we are doing training all the time, taking classes and so forth," Mr. Friedenfelds said. "Were starting to see that you could prevent some of these things if you were just a bit different in the way you approach a particular individual, and secondly, if you felt there was a problem, not going alone, perhaps, in a room and having those kind of tactics can help prevent some of this kind of stuff."
At Rush, polling the staff helped indicate its main safety concern: Managing visitors, Mr. Freidenfelds said.
"We took a venture to implement a very protective visitor management system," he said.
Implemented in 2019, every person planning on getting to an inpatient unit is screened and given a badge.
"It made the nurses feel comfortable that we on the ground floor were taking care and making sure that individuals, perhaps because of a previous encounter, aren't getting back up there. I think that was the biggest impact where we had the biggest return," Mr. Friedenfelds said.
Those in charge of security should also be looking for opportunities where technology can cut costs, Mr. Snow said.
For instance, Cleveland Clinic switched from analog cameras to digital ones because they had wider coverage.
"We found ourselves putting in one camera where two or three or four cameras had been because they have a 360-degree coverage," he said.
That reduced the number of wire poles, labor and installation costs required for analog cameras.
"Just like everything in healthcare, you're trying to cut the cost as much as you can," Mr. Snow said. "But sometimes cutting costs doesn't necessarily mean cutting the service or cutting the capability."