Selected Podcast
Reducing Violence in Health Care Settings – Lessons From the Mayo Clinic
In this panel interview, Rebecca Chickey, MPH, and Dr. Neel Shah shares the different preventative measures hospitals are taking to reduce violence in hospitals.
Featuring:
Rebecca Chickey is the American Hospital Association's Senior Director, Behavioral Health. In this role she serves as the AHA field engagement, subject matter expert on behavioral health -- a strategic priority area for the AHA. Curator of resources in behavioral health for over 5,000 member hospitals and health systems, she serves as a thought leader and agent of change to deliver exceptional member experience.
Over the past several years at AHA, Chickey has had a leadership role with numerous projects, including the passage of the 2008 Mental Health Parity and Addiction Equity Act, and the creation and implementation of Medicare’s Inpatient Psychiatric Facility Prospective Payment System. A broad-based expert in behavioral health, she works across AHA on health policy, advocacy, innovation and delivery system transformation. Beyond improving reimbursement, key priority areas include expanding the integration of physical and behavioral health services; increasing the number and impact of community based collaborative partnerships to improve access to care; addressing workforce shortages and reducing stigma.
Ms. Chickey has been in the health care field for more than 35 years and has experience in strategic planning, marketing, the development and implementation of educational conferences and a range of financial and investment initiatives in both the for-profit and not-for-profit sectors. She has undergraduate degrees in business and psychology from Rhodes College and a master’s degree in public administration and health care from the University of Memphis.
Neel Shah, MD | Rebecca Chickey, MPH
Dr. Shah is a Consultant Hospitalist at Mayo Clinic Hospital in Rochester, Minnesota. He studied medicine at the University of Edinburgh and completed his internship at the Manchester Royal Infirmary in the United Kingdom, before Internal Medicine residency at the University of Illinois at Chicago and fellowship in Medical Genetics at Mayo Clinic Rochester. He is currently studying for his Master’s in Health Professions Education at Johns Hopkins University. Mayo has developed a comprehensive violent patient program that now spans the entire practice from clinic and pre-hospital care, though to all hospital campuses across the Mayo Clinic Health System. Neel leads the Mayo Clinic Complex Behavior Committee that oversees policy and programs to reduce complex behavior among both patients and visitors. He serves as Medical Director of the Behavior Emergency Response Team (BERT) and Complex Intervention Unit (CIU). The CIU is a purpose built inpatient unit designed to reduce the incidence of healthcare workplace violence across Mayo Clinic Rochester. He also participated in the development of the Vizient Workplace Violence Benchmarking Study last year.Rebecca Chickey is the American Hospital Association's Senior Director, Behavioral Health. In this role she serves as the AHA field engagement, subject matter expert on behavioral health -- a strategic priority area for the AHA. Curator of resources in behavioral health for over 5,000 member hospitals and health systems, she serves as a thought leader and agent of change to deliver exceptional member experience.
Over the past several years at AHA, Chickey has had a leadership role with numerous projects, including the passage of the 2008 Mental Health Parity and Addiction Equity Act, and the creation and implementation of Medicare’s Inpatient Psychiatric Facility Prospective Payment System. A broad-based expert in behavioral health, she works across AHA on health policy, advocacy, innovation and delivery system transformation. Beyond improving reimbursement, key priority areas include expanding the integration of physical and behavioral health services; increasing the number and impact of community based collaborative partnerships to improve access to care; addressing workforce shortages and reducing stigma.
Ms. Chickey has been in the health care field for more than 35 years and has experience in strategic planning, marketing, the development and implementation of educational conferences and a range of financial and investment initiatives in both the for-profit and not-for-profit sectors. She has undergraduate degrees in business and psychology from Rhodes College and a master’s degree in public administration and health care from the University of Memphis.
Transcription:
Michael Carrese (Host): Welcome to the ASHRM podcast made possible by the American Society for Healthcare Risk Management to support efforts to advance safe and trusted healthcare through enterprise risk management. You can visit www.ashrm.org/membership to learn more and become an ASHRM member. I’m Michael Carrese and 25,000 workplace assaults occur annually in healthcare settings in the US and unfortunately, many experts expect that number to continue increasing. This is a major challenge for these organizations, and it’s lead the American Hospital Association to create the Hospitals Against Violence Initiative which is sharing best practices and supporting members in their efforts to reduce workplace violence. One place to turn for an example is Mayo Clinic which has developed a comprehensive violent patient program that now spans the entire practice from clinic and prehospital care through all the hospital campuses across the Mayo Clinic Health System. We have representatives from the AHA and Mayo on today’s show to provide detail on all of this. Dr. Neel Shah is a consultant hospitalist at Mayo Clinic Hospital in Rochester, Minnesota and leads the Complex Behavior Committee that overseas policy and programs to reduce complex behavior among both patients and visitors and Rebecca Chickey is the American Hospital Association Senior Director of Behavioral Health, helping the AHA’s 5000 members find and tap resources on important subjects just like this one. So, thanks to both of you for being with us today.
Rebecca Chickey, MPH (Guest): Thank you. Thank you, Michael, and thank you Dr. Shah. On behalf of the American Hospital Association, and it’s work to reduce workplace and workforce violence, and to all the listeners on this podcast, Dr. Shah, we want to thank you for your willingness to share your time, your expertise and your inspiration in this important issue area. As the Senior Director of Behavioral Health Services at the AHA, I’m especially grateful to you to have you address this important issue and to help AHA continue to dispel the myths that all behavioral health patients are violent. Often, that is a stigma that has been illustrated in the media, in the press and the fact that I think it’s so critical to hear what you have done at Mayo is that this is a comprehensive program that you have developed to address complex behavior by all patients, not just those who may have a clinical diagnosis of a psychiatric or substance use disorder. So, thank you so much. I will turn it right now back over to Michael so that we can begin to listen and learn from your experience.
Host: Yeah, so actually why don’t we start Dr. Shah by having you tell us a little bit more about you and your role at Mayo?
Neel Shah, MD (Guest): Well you will notice I am not a psychiatrist. So, to the point of the presumption that this is a problem that is limited to behavioral health, as a hospitalist, I came to this issue through the general hospital where we are seeing staff assaults and injuries and it was disrupting the patient’s own care and it was certainly disrupting hospital flows and causing decrease in morale and increase in attrition with the staff and had become in an of itself, a recognized problem and one though that falls between the cracks because naturally if one takes the view that it’s psychiatric problem and if you ever speak to psychiatrists about this, they don’t see it as a passive field intrinsically assuming they are willing to be partners but it’s not something that they ought to own individually and obviously, it effects many departments besides the inpatient practice. As you mentioned, the outpatient practice, certainly the emergency department, certainly the intensive care units, ambulance services. So, we really started to look and when you look, you find that indeed people have been finding their own solutions and making do and suddenly you come in and say we’re interested in what your ideas are, how we might solve it, how we might support you and of course, you learn as well that their own ad hoc solutions were actually pretty ingenious and very effective and can be applied elsewhere. So, that’s the whole premise of bringing all the stakeholders together for mutual benefit and of course setting from the enterprise and the institutional level the standard that staff will not have to tolerate this sort of behavior. It’s not part of their job that the institution and the teams themselves are empowered and empowering employees to try to remedy problems that they have and innovate and try to minimize the issue and the threat of violence.
Host: You know I think probably most people think about these sorts of incidents happening in the emergency room but is it well beyond that now and if you can give me a sense of the kind of range of incidence. Are we going from pushing to how violent does it get I guess is another way of asking that question.
Dr. Shah: You know unfortunately, it’s also – violence is a problem with our society at large and so to some extent, healthcare is a reflection of the society that it serves. And that might account for some of the increased trends. But then there are other problems that are intrinsic to healthcare. So, if you think about problems with certain conditions and so besides psychotic disorders, there’s intoxication, alcohol withdrawal, delirium, dementia, intellectual disability and autism. These are things that will always find their home somewhere in the health system and therefore we have a little bit of our own unique challenges to deal with that other workplaces clearly don’t.
As for the range of violence, so of course we can look at the issues of physicians and other staff being assassinated and that has happened and that’s really the worst extreme, very few and far between but it cannot be ignored that this problem can reach that level. On the other hand, it can be down to the level of smaller aggressions where people are disrespectful or willfully disruptive and behaving in a way that makes the staff feel threatened and inevitably, makes the staff now lose their focus on purely healthcare issues and that again, backfires on the patient whether they realize it or not, that their staff are perhaps distracted and not able to concentrate just on the healthcare issues at hand. There are consequences even at that lower level.
As for the areas of the practice, well I think one truism is if you look you will find and if you don’t look then you can be blissfully unaware but the emergency department is obvious because people are not stabilized at the front door and police and other community staff will bring people in through the emergency department but once they’ve been triaged, they may be off into the acute hospital, certainly psychiatric care, they may be dismissed into the community and then the clinic has to see them. They may not be, and they may even continue to escalate. So, it’s not the emergency department is able to solve the problem there and then and nor is that their responsibility. But it happens that people often pass through that route.
When it comes to where in the hospital, we have the highest incidence; we certainly think the ICU is an area, medicine and general inpatient medicine, the postop areas also as people are dealing with the effects of anesthesia.
Host: Yeah, so as you suggest, that’s really kind of widespread at this point.
Dr. Shah: It’s very widespread and some specialties, neurology is one that may surprise people and certain clinics we’ve got HIV clinic, we have certain primary care where issues of opioid use being discussed. So, if you look, you will find and it’s not something that you can say belongs therefore it’s a one department. That’s really – that’s a failing strategy if you assign this issue, the solutions have to come from all angles that are outside of the abilities of one department to manage.
Host: Right. So, let’s talk about how you make this a successful strategy and if you could just kind of summarize for us Mayo’s approach and the key elements of your plan.
Dr. Shah: So, it really has to be a comprehensive strategy. There is a lack of evidence. We’re working on that as to which individual components are the most useful or less useful. We actually did a national benchmarking study late last year that was published this year on the – how widespread various components are across the country. That was very revealing. There were certain themes that came out. But it was also clear that most hospitals are also starting to see more and more that they can’t simply put more resources into say the emergency department or hiring trained nurses to manage escalating behavior or working on the EMR and identifying these patients. Those are examples of things that can be helpful but as like with any chain, as soon as you move the patients into the next link in the chain, if there’s a weakness, that might be the break point.
If I had to list the components of a comprehensive workplace plan, I would say screening and access management, training and education of staff, communication of data, certain new measures coming in is very important. The response, so how do you phone security or a response team to an event, documenting the fact that the patient may have a risk of escalation or have a past history of behavior, the environmental design and modifications and the organizational commitment. Because nothing will happen unless your leaders are onboard and are buying into the belief that if you protect the staff that care for the patients, then the patients which is the primary goal of any healthcare institution will be the first victims.
Host: So, talk about how this has worked out at Mayo. How has it improved processes and staff performance and wellbeing overall?
Dr. Shah: And so our projects have happened in sequence. It’s not been all at once and so year by year, as say the background rates of violence has continued to rise in the country; we’ve seen massive improvements when we’ve brought in new measures. One example would be we built a purpose built complex intervention unit which was staffed by medicine and psychiatry and trained nursing and was purpose built to minimize risk. And that had a massive effect when we were able to draw in now the highest risk patients which were themselves being identified systematically and referrals were being put in base don certain criteria but with the background rate increasing, you also see the effects of that lessening gradually each year and it’s brought us to the point where we are thinking now what more can we do, what additional training do our staff need. Do we expand the unit? It brought to light that pediatrics is facing a much greater challenge than we previously anticipated and so that needs to be a much more central part of the plan. And so I think as we go through PDSA cycles, we see that okay this is having a good effect, let’s double down. This is not so much, let’s focus our attention elsewhere but each endeavor tries to move things forward and we have kept events under control but at the same time, I’ll be the first to admit that we suffer as everyone does from incomplete reporting and you can never get to the level where you think that just because you’ve encouraged the staff to report and you’ve given them pathways and you get people to report more than they did before; that that behavior will continue or that they won’t start to reset the bar and say okay I will – I’m perfectly willing to report if it crosses a certain line but I’ll also start to be a bit more tolerant of low level behavior which is precisely what we want to encourage people to not tolerate.
But it’s natural that reporting is burdensome if people don’t feel that there’s a response made to address their experiences and so it’s a work in process that we have to continually ask for feedback and continually make improvements where we can.
Host: So, I think it would be helpful for our audience to hear an example or two of any barriers or challenges that you’ve faced trying to implement the comprehensive violent patient program at Mayo and how you overcame them.
Dr. Shah: There are barriers. So, we have to make our case for making modifications to the electronic medical record that naturally will process needs to be justified and there are other requests from other areas, and they need to be prioritized so, that’s one example. I would say investments in training, physical modifications. That’s clearly an investment that hospital leaders need to examine the utility of and see if money would be best spent elsewhere. Again, you have to make your case. I would say one of the important things in dealing with healthcare violence is to realize that our metrics are not the same as other fields within medicine. We’re not talking about wrong side surgery or length of stay, but we do have metrics. If you look, you’ll find those. So, of course, the number of events, the number of staff that feel threatened in a given period, the time off work or on work restrictions, the number of security calls, the amount of cost of repairing damage from any events really are metrics out there. And once you start to utilize things like the EMR, then you can actually gather even more data. So, once you’ve identified that a patient has a higher risk, you can track their length of stay and see if it’s prolonged versus anybody else and that can become a justification.
So, it’s important that you adapt to your own environment. I think the teams themselves will know how to measure best the effects. I think at the unit level, nurse managers, certainly the local clinical staff can tell you that morale has been affected. We need to actually do a survey of that. So, adapting to novel metrics and then making the case to your leadership. So, one of the strategies we used was we set a culture of every week sending an email summarizing the events that had happened in that week and it had never happened before. And certainly, it had two effects. Number one all the big events were being systematically sent out which previously they may have been on an ad hoc basis to a variable group of leaders. Now it was happening in a predetermined way and that opens eyes immediately. And second of all, you are now reporting a slightly lower level than when you were doing it on an ad hoc basis so, the volume starts to get reflected.
And so that was one of the first steps that got our board moving when we showed that Mayo Clinic is not a ivory tower that we are part of the US Healthcare system and this challenge faces all hospitals and we need to find our own solutions to it that our staff who are here to do their very best are suffering with something that was not at the forefront of our leaders’ minds up until the point that we made it.
Host: So, as we wrap up here, if you could boil it down to just maybe one piece of advice for the other hospitals who are interested in implementing this kind of a program what would it be?
Dr. Shah: I really think the first step that people can make is to ask the staff what their concerns are, if they’ve experienced this. You have to get that whether it’s from a survey or just huddling with them. Once you’ve ascertained what their concerns are, then actually ask them for their suggestions. They may have already as I alluded to earlier, been working on things and you can learn from what they’ve been doing. You can support it more. You can elevate it to a much higher level but if you can engage with the staff and use their expertise, they are dedicated. They want – what they really want from the institution is their backing and after we’ve given them their backing that they need, we should stand back and let them implement their own changes. But it can’t happen in a top down way and nor can it be solved in a bottom up way. It has to be also that strong collaboration between leaders and the frontline staff.
Host: Rebecca Chickey, so obviously I’m sure you would support the sentiments there about staff involvement. What else would you like to share with us about the Mayo approach and your thoughts on it?
Rebecca: In general, I think that the comprehensive approach that Mayo is taking is fundamental to reducing overall violence in the workforce. As Dr. Shah indicated, violence is found everywhere but when it is prevalent in a workforce environment, it can do such significant harm to any workforce in terms of what their end goal is trying to achieve. But particularly when your workforce is addressing the healthcare needs of individuals. So, I’m going to take a little bit of liberty here Dr. Shah, I know that we haven’t mentioned COVID-19 yet. But clearly, we have been and still are in the midst of unusual pandemic and I would think that having in place already such a program where staff can have their voice heard, where they can influence change that that has been critical and by making this a broad and not specific to a particular clinical service line or unit; that that has also bolstered and changed and created a culture where speaking up is not seen as a complaint but speaking up about concerns is seen as an opportunity to improve change and to better support the staff that are critical to all hospital and health systems. So, for that, I compliment you highly.
Host: And Rebecca where can listeners get more information on what to do about workplace violence? I know the AHA has a lot of resources.
Rebecca: Sure the central place that I would point you to most easily is the website on Hospitals Against Violence and it has quite an easy address. It’s www.aha.org/hav, so www.aha.org/hav for hospitals against violence.
Host: All right. That’s easy enough for folks to remember and I hope you will check it out and I want to thank both of you very much for being with us today. This is obviously a very, very important topic and you’ve been sharing a lot of great information that I’m sure our listeners will benefit from. So, thanks for being here. You’ve been listening to Dr. Neel Shah a Consultant Hospitalist at Mayo Clinic in Rochester, and he leads the Complex Behavior Committee that overseas policies and programs to reduce complex behavior among patients and visitors. And Rebecca Chickey who was also with us. She’s the American Hospital Association’s Senior Director of Behavioral Health. This podcast is made possible by the American Society for Healthcare Risk Management to support efforts to advance safe and trusted healthcare through enterprise risk management. You can visit www.ashrm.org/membership to learn more and become an ASHRM member. I’m Michael Carrese. Thanks for listening.
Michael Carrese (Host): Welcome to the ASHRM podcast made possible by the American Society for Healthcare Risk Management to support efforts to advance safe and trusted healthcare through enterprise risk management. You can visit www.ashrm.org/membership to learn more and become an ASHRM member. I’m Michael Carrese and 25,000 workplace assaults occur annually in healthcare settings in the US and unfortunately, many experts expect that number to continue increasing. This is a major challenge for these organizations, and it’s lead the American Hospital Association to create the Hospitals Against Violence Initiative which is sharing best practices and supporting members in their efforts to reduce workplace violence. One place to turn for an example is Mayo Clinic which has developed a comprehensive violent patient program that now spans the entire practice from clinic and prehospital care through all the hospital campuses across the Mayo Clinic Health System. We have representatives from the AHA and Mayo on today’s show to provide detail on all of this. Dr. Neel Shah is a consultant hospitalist at Mayo Clinic Hospital in Rochester, Minnesota and leads the Complex Behavior Committee that overseas policy and programs to reduce complex behavior among both patients and visitors and Rebecca Chickey is the American Hospital Association Senior Director of Behavioral Health, helping the AHA’s 5000 members find and tap resources on important subjects just like this one. So, thanks to both of you for being with us today.
Rebecca Chickey, MPH (Guest): Thank you. Thank you, Michael, and thank you Dr. Shah. On behalf of the American Hospital Association, and it’s work to reduce workplace and workforce violence, and to all the listeners on this podcast, Dr. Shah, we want to thank you for your willingness to share your time, your expertise and your inspiration in this important issue area. As the Senior Director of Behavioral Health Services at the AHA, I’m especially grateful to you to have you address this important issue and to help AHA continue to dispel the myths that all behavioral health patients are violent. Often, that is a stigma that has been illustrated in the media, in the press and the fact that I think it’s so critical to hear what you have done at Mayo is that this is a comprehensive program that you have developed to address complex behavior by all patients, not just those who may have a clinical diagnosis of a psychiatric or substance use disorder. So, thank you so much. I will turn it right now back over to Michael so that we can begin to listen and learn from your experience.
Host: Yeah, so actually why don’t we start Dr. Shah by having you tell us a little bit more about you and your role at Mayo?
Neel Shah, MD (Guest): Well you will notice I am not a psychiatrist. So, to the point of the presumption that this is a problem that is limited to behavioral health, as a hospitalist, I came to this issue through the general hospital where we are seeing staff assaults and injuries and it was disrupting the patient’s own care and it was certainly disrupting hospital flows and causing decrease in morale and increase in attrition with the staff and had become in an of itself, a recognized problem and one though that falls between the cracks because naturally if one takes the view that it’s psychiatric problem and if you ever speak to psychiatrists about this, they don’t see it as a passive field intrinsically assuming they are willing to be partners but it’s not something that they ought to own individually and obviously, it effects many departments besides the inpatient practice. As you mentioned, the outpatient practice, certainly the emergency department, certainly the intensive care units, ambulance services. So, we really started to look and when you look, you find that indeed people have been finding their own solutions and making do and suddenly you come in and say we’re interested in what your ideas are, how we might solve it, how we might support you and of course, you learn as well that their own ad hoc solutions were actually pretty ingenious and very effective and can be applied elsewhere. So, that’s the whole premise of bringing all the stakeholders together for mutual benefit and of course setting from the enterprise and the institutional level the standard that staff will not have to tolerate this sort of behavior. It’s not part of their job that the institution and the teams themselves are empowered and empowering employees to try to remedy problems that they have and innovate and try to minimize the issue and the threat of violence.
Host: You know I think probably most people think about these sorts of incidents happening in the emergency room but is it well beyond that now and if you can give me a sense of the kind of range of incidence. Are we going from pushing to how violent does it get I guess is another way of asking that question.
Dr. Shah: You know unfortunately, it’s also – violence is a problem with our society at large and so to some extent, healthcare is a reflection of the society that it serves. And that might account for some of the increased trends. But then there are other problems that are intrinsic to healthcare. So, if you think about problems with certain conditions and so besides psychotic disorders, there’s intoxication, alcohol withdrawal, delirium, dementia, intellectual disability and autism. These are things that will always find their home somewhere in the health system and therefore we have a little bit of our own unique challenges to deal with that other workplaces clearly don’t.
As for the range of violence, so of course we can look at the issues of physicians and other staff being assassinated and that has happened and that’s really the worst extreme, very few and far between but it cannot be ignored that this problem can reach that level. On the other hand, it can be down to the level of smaller aggressions where people are disrespectful or willfully disruptive and behaving in a way that makes the staff feel threatened and inevitably, makes the staff now lose their focus on purely healthcare issues and that again, backfires on the patient whether they realize it or not, that their staff are perhaps distracted and not able to concentrate just on the healthcare issues at hand. There are consequences even at that lower level.
As for the areas of the practice, well I think one truism is if you look you will find and if you don’t look then you can be blissfully unaware but the emergency department is obvious because people are not stabilized at the front door and police and other community staff will bring people in through the emergency department but once they’ve been triaged, they may be off into the acute hospital, certainly psychiatric care, they may be dismissed into the community and then the clinic has to see them. They may not be, and they may even continue to escalate. So, it’s not the emergency department is able to solve the problem there and then and nor is that their responsibility. But it happens that people often pass through that route.
When it comes to where in the hospital, we have the highest incidence; we certainly think the ICU is an area, medicine and general inpatient medicine, the postop areas also as people are dealing with the effects of anesthesia.
Host: Yeah, so as you suggest, that’s really kind of widespread at this point.
Dr. Shah: It’s very widespread and some specialties, neurology is one that may surprise people and certain clinics we’ve got HIV clinic, we have certain primary care where issues of opioid use being discussed. So, if you look, you will find and it’s not something that you can say belongs therefore it’s a one department. That’s really – that’s a failing strategy if you assign this issue, the solutions have to come from all angles that are outside of the abilities of one department to manage.
Host: Right. So, let’s talk about how you make this a successful strategy and if you could just kind of summarize for us Mayo’s approach and the key elements of your plan.
Dr. Shah: So, it really has to be a comprehensive strategy. There is a lack of evidence. We’re working on that as to which individual components are the most useful or less useful. We actually did a national benchmarking study late last year that was published this year on the – how widespread various components are across the country. That was very revealing. There were certain themes that came out. But it was also clear that most hospitals are also starting to see more and more that they can’t simply put more resources into say the emergency department or hiring trained nurses to manage escalating behavior or working on the EMR and identifying these patients. Those are examples of things that can be helpful but as like with any chain, as soon as you move the patients into the next link in the chain, if there’s a weakness, that might be the break point.
If I had to list the components of a comprehensive workplace plan, I would say screening and access management, training and education of staff, communication of data, certain new measures coming in is very important. The response, so how do you phone security or a response team to an event, documenting the fact that the patient may have a risk of escalation or have a past history of behavior, the environmental design and modifications and the organizational commitment. Because nothing will happen unless your leaders are onboard and are buying into the belief that if you protect the staff that care for the patients, then the patients which is the primary goal of any healthcare institution will be the first victims.
Host: So, talk about how this has worked out at Mayo. How has it improved processes and staff performance and wellbeing overall?
Dr. Shah: And so our projects have happened in sequence. It’s not been all at once and so year by year, as say the background rates of violence has continued to rise in the country; we’ve seen massive improvements when we’ve brought in new measures. One example would be we built a purpose built complex intervention unit which was staffed by medicine and psychiatry and trained nursing and was purpose built to minimize risk. And that had a massive effect when we were able to draw in now the highest risk patients which were themselves being identified systematically and referrals were being put in base don certain criteria but with the background rate increasing, you also see the effects of that lessening gradually each year and it’s brought us to the point where we are thinking now what more can we do, what additional training do our staff need. Do we expand the unit? It brought to light that pediatrics is facing a much greater challenge than we previously anticipated and so that needs to be a much more central part of the plan. And so I think as we go through PDSA cycles, we see that okay this is having a good effect, let’s double down. This is not so much, let’s focus our attention elsewhere but each endeavor tries to move things forward and we have kept events under control but at the same time, I’ll be the first to admit that we suffer as everyone does from incomplete reporting and you can never get to the level where you think that just because you’ve encouraged the staff to report and you’ve given them pathways and you get people to report more than they did before; that that behavior will continue or that they won’t start to reset the bar and say okay I will – I’m perfectly willing to report if it crosses a certain line but I’ll also start to be a bit more tolerant of low level behavior which is precisely what we want to encourage people to not tolerate.
But it’s natural that reporting is burdensome if people don’t feel that there’s a response made to address their experiences and so it’s a work in process that we have to continually ask for feedback and continually make improvements where we can.
Host: So, I think it would be helpful for our audience to hear an example or two of any barriers or challenges that you’ve faced trying to implement the comprehensive violent patient program at Mayo and how you overcame them.
Dr. Shah: There are barriers. So, we have to make our case for making modifications to the electronic medical record that naturally will process needs to be justified and there are other requests from other areas, and they need to be prioritized so, that’s one example. I would say investments in training, physical modifications. That’s clearly an investment that hospital leaders need to examine the utility of and see if money would be best spent elsewhere. Again, you have to make your case. I would say one of the important things in dealing with healthcare violence is to realize that our metrics are not the same as other fields within medicine. We’re not talking about wrong side surgery or length of stay, but we do have metrics. If you look, you’ll find those. So, of course, the number of events, the number of staff that feel threatened in a given period, the time off work or on work restrictions, the number of security calls, the amount of cost of repairing damage from any events really are metrics out there. And once you start to utilize things like the EMR, then you can actually gather even more data. So, once you’ve identified that a patient has a higher risk, you can track their length of stay and see if it’s prolonged versus anybody else and that can become a justification.
So, it’s important that you adapt to your own environment. I think the teams themselves will know how to measure best the effects. I think at the unit level, nurse managers, certainly the local clinical staff can tell you that morale has been affected. We need to actually do a survey of that. So, adapting to novel metrics and then making the case to your leadership. So, one of the strategies we used was we set a culture of every week sending an email summarizing the events that had happened in that week and it had never happened before. And certainly, it had two effects. Number one all the big events were being systematically sent out which previously they may have been on an ad hoc basis to a variable group of leaders. Now it was happening in a predetermined way and that opens eyes immediately. And second of all, you are now reporting a slightly lower level than when you were doing it on an ad hoc basis so, the volume starts to get reflected.
And so that was one of the first steps that got our board moving when we showed that Mayo Clinic is not a ivory tower that we are part of the US Healthcare system and this challenge faces all hospitals and we need to find our own solutions to it that our staff who are here to do their very best are suffering with something that was not at the forefront of our leaders’ minds up until the point that we made it.
Host: So, as we wrap up here, if you could boil it down to just maybe one piece of advice for the other hospitals who are interested in implementing this kind of a program what would it be?
Dr. Shah: I really think the first step that people can make is to ask the staff what their concerns are, if they’ve experienced this. You have to get that whether it’s from a survey or just huddling with them. Once you’ve ascertained what their concerns are, then actually ask them for their suggestions. They may have already as I alluded to earlier, been working on things and you can learn from what they’ve been doing. You can support it more. You can elevate it to a much higher level but if you can engage with the staff and use their expertise, they are dedicated. They want – what they really want from the institution is their backing and after we’ve given them their backing that they need, we should stand back and let them implement their own changes. But it can’t happen in a top down way and nor can it be solved in a bottom up way. It has to be also that strong collaboration between leaders and the frontline staff.
Host: Rebecca Chickey, so obviously I’m sure you would support the sentiments there about staff involvement. What else would you like to share with us about the Mayo approach and your thoughts on it?
Rebecca: In general, I think that the comprehensive approach that Mayo is taking is fundamental to reducing overall violence in the workforce. As Dr. Shah indicated, violence is found everywhere but when it is prevalent in a workforce environment, it can do such significant harm to any workforce in terms of what their end goal is trying to achieve. But particularly when your workforce is addressing the healthcare needs of individuals. So, I’m going to take a little bit of liberty here Dr. Shah, I know that we haven’t mentioned COVID-19 yet. But clearly, we have been and still are in the midst of unusual pandemic and I would think that having in place already such a program where staff can have their voice heard, where they can influence change that that has been critical and by making this a broad and not specific to a particular clinical service line or unit; that that has also bolstered and changed and created a culture where speaking up is not seen as a complaint but speaking up about concerns is seen as an opportunity to improve change and to better support the staff that are critical to all hospital and health systems. So, for that, I compliment you highly.
Host: And Rebecca where can listeners get more information on what to do about workplace violence? I know the AHA has a lot of resources.
Rebecca: Sure the central place that I would point you to most easily is the website on Hospitals Against Violence and it has quite an easy address. It’s www.aha.org/hav, so www.aha.org/hav for hospitals against violence.
Host: All right. That’s easy enough for folks to remember and I hope you will check it out and I want to thank both of you very much for being with us today. This is obviously a very, very important topic and you’ve been sharing a lot of great information that I’m sure our listeners will benefit from. So, thanks for being here. You’ve been listening to Dr. Neel Shah a Consultant Hospitalist at Mayo Clinic in Rochester, and he leads the Complex Behavior Committee that overseas policies and programs to reduce complex behavior among patients and visitors. And Rebecca Chickey who was also with us. She’s the American Hospital Association’s Senior Director of Behavioral Health. This podcast is made possible by the American Society for Healthcare Risk Management to support efforts to advance safe and trusted healthcare through enterprise risk management. You can visit www.ashrm.org/membership to learn more and become an ASHRM member. I’m Michael Carrese. Thanks for listening.