Bill Klaproth (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 ASHRM.org, that's A-S-H-R-M.org/membership, to learn more and to become an ASHRM member. I'm Bill Klaproth.

Host: In this podcast, we'll be addressing workplace violence in the physician practice setting with Tatum O'Sullivan, Director of Ambulatory Risk and Patient Safety at North Shore Physicians Group. She is also the President-Elect for ASHRM. Tatum, welcome to the podcast.

Tatum O'Sullivan: Thank you, Bill. I'm happy to be here. Before we begin, I wanted to take a quick minute to wish the risk professionals listening a Happy Healthcare Risk Management Week. This week is dedicated to celebrating our vital role as risk professionals, and I wanted to express my gratitude for all they do.

Host: Absolutely. Very well said, and thank you for that. This is really an important topic, Tatum, and I'm glad we're having a chance to talk about it. But first off, can you tell us a little bit about yourself and your role within your organization?

Tatum O'Sullivan: Sure. I've been a nurse for 27 years, 16 of those have been in risk management. I did work in a community hospital setting a couple times prior to taking this position with a large physician practice group. We're part of the Mass General Brigham system that's located in New England. I'm their first risk manager, and I started here in 2012. I was initially the risk manager and then I became the Director of Risk and Patient Safety. It's been a great position to be in because I've been able to develop the role and have it grow as the time has gone on.

Host: So, you're the perfect person to talk to about this as we talk about workplace violence in the physician practice setting. So Tatum, how would you describe workplace violence?

Tatum O'Sullivan: Even though we're not accredited by the Joint Commission, I still like to use their definition here at North Shore Physicians Group. So, that's any act or threat that can include verbal, non-verbal, written or physical aggression. And these events can include anyone within the organization. In our case, it's mostly staff members, vendors, patients or visitors.

And the majority of our events that we're seeing in the medical offices are verbal assaults that are geared towards staff members coming from patients or their family members, Our front desk staff seem to be the biggest target right now, and that's with verbal assaults and threats. And after them, we'll see medical assistants and then nurse practitioners and other clinicians being on the receiving end of this behavior.

Host: Yeah. So, verbal, non-verbal, written or physical aggression. And unfortunately, those working in healthcare are encountering workplace violence much more frequently than prior years. So, what are you doing to track and trend these occurrences?

Tatum O'Sullivan: We've just recently started to track and trend them. About two years ago, we began discussing workplace violence. After the pandemic, we were seeing patient behavior be a little different than what we encountered in 2020 and 2021, where there were feelings of gratitude. Those feelings have seemed to turn into some hostility and even anger towards staff. And so, because of that, we've started to address workplace violence.

What I'm doing is I track the location of events, the number of events by month. And then, I break them down into verbal, physical threat. And then, we also capture discriminatory in nature. And then, I share demographic data related to the aggressor as well. And that's something that I've been sharing on a monthly basis. And recently, I started tracking which staff members seem to be the target. And I shared that information with you, finding that our front desk staff are really taking the brunt of this behavior.

Host: Wow. That is amazing how you're breaking all of that down. I'm sure that it really helps you address this, understanding where this is coming from or who it's directed at and what type of workplace violence is being directed at these people. So knowing this, what is your organization doing to address workplace violence?

Tatum O'Sullivan: Our VP of Operations assembled a safety and security guiding team. And so, that's made up of representation from senior leadership; risk and patient safety, which is me; DE&I Committee members and security from the hospital, which we partner with. It's important to note that we do not have security on site. We have many different locations and none of them are serviced with security guards anywhere within our buildings. But because we do partner with the hospital, we've been able to have them be a part of our committee, which is excellent because they are experts in this area. And then, we also include social work and site leadership, which can include administrative directors, managers and medical directors. But just in answering this, what I've noticed is that we don't really have frontline staff as part of the group, and I think that's a critical component that we've been missing from our team. And that I'd like to pursue adding some frontline staff there as well. Through the group though, we've been able to develop a formal approach to addressing workplace violence. What we do is promote safety event reporting. I debrief with any staff member that's been involved in an event, so I'll call them or I'll huddle with them.

And my first and foremost approach is to provide support because this can be really upsetting. What I've noticed when I've met with staff is everyone takes in these situations differently. And for some, I've heard them say, "This makes me feel the same way I did when I was in an abusive relationship," or "This brings me back to a time when somebody else spoke to me this way." And it's really important that we're providing that support to staff, so that they can explore those feelings and that we can get them the help that they need. And so, I'll often offer EAP. I'll also send an email afterwards thanking them for meeting with me and, again, giving them a line to communicate with EAP if they need that.

But other things that we do is we decide how are we going to follow up with this patient? How are we going to manage future interactions? Is this something that we should be discharging the patient or family member, not being allowed to come to the office? Or should we be warning them? And so, we talk about that. And we also share the code of conduct with the patients as well, which basically tells them that words or actions that are disrespectful, hostile or harassing are not welcome. Through this group, we've been able to develop a formal approach for addressing workplace violence. The first thing we do is promote reporting of these events. We've been able to add a workplace violence icon in our safety event reporting system, and that's really helped to remind staff and capture what they're seeing in the offices.

And then, next, I debrief with anyone that's reported an event and those involved. And so, we'll have a conversation and we'll find out what happened. What do they think would've been helpful to have on hand at the time it occurred? Do they need any support? And so, some staff members say that they're okay. And then, others say that this has brought up some maybe past trauma or concerns that they've had related on experiences from their past. And so, I like to offer EAP to anyone involved. Most individuals will decline, but I still send them an email with that contact information involved. And then, I do share a code of conduct with the office to include in the warning with the patient if the patient is going to be warned, that this behavior is not acceptable. And that code of conduct is really a one-page handout and the warning letter will include that any words or actions that are disrespectful, hostile or harassing are not welcome. And sometimes we do discharge a patient. It's on a rare occasion, but that has happened based on the behavior that we're seeing.

And then, we also offer deescalation training. It's a mandatory part of the annual training that occurs by April every year. And we've added onto it another portion that digs a little deeper into the deescalation techniques, but also ways to approach a patient or visitor, body language of ourselves and those around us and the awareness of surroundings and exits.

And then from there, we had our security team from the hospital come out and do an analysis at each office. And so, they'll go on site, they'll look at the physical layout, they'll interview staff, and they'll also have discussions about armed intruder reviews, because every physical setting is a little bit different, and so it's not a one-size-fits-all. Some of our offices have locked doors from the waiting room to the treatment area, whereas others, unfortunately, are a little bit more open and there's different things that need to be considered there. So, we've been grateful to be able to have those visits completed.

And then, in the upcoming months, we're going to begin sharing actual scenarios that have occurred in the offices. So, the site leaders will get these little explanations of what's happened and share it with their staff and have discussions as to what would be a great way to deescalate or manage the situation. And so, just making it a little bit more interactive at each meeting, we're hoping we'll help with some of our responses.

And then, finally, we're going to offer a CME or CEU program, which I find that offering credits helps to get the most people to attend. And that session will be hosted by one of my ASHRM peers actually, who specializes in workplace violence and behavioral health. And she'll share her insights related to the practice setting and touch on some aspects of trauma-informed care. Because we spend a great deal of time discussing deescalation and communication, we haven't really explored understanding the behaviors that those originate from. And so, it's easy to forget how intrusive healthcare can be. We ask personal questions. We get close in a patient's personal space. And patients may perceive those interactions very differently based on their past experiences. So, I want to make sure we're covering that in our discussions as well.

Host: Tatum, that is a really thorough and comprehensive plan/process that you've put together on how to deal with workplace violence. So, thank you for sharing that information. I know that will be very beneficial to anyone listening to this podcast. So, how does your organization handle events then that involve an element of discrimination or racism?

Tatum O'Sullivan: Within our safety event reporting system, we do have a field for all events that asks if there's an element of discrimination or racism so that staff members can think about that and then respond to that as well. Something that we're really starting to look at though and hearing about in healthcare is implicit bias, which is the subconscious or hidden bias that refers to our attitudes or stereotypes that affect our actions or decisions. And many times, we're not aware of this. And in situations involving workplace violence, what they found is that staff might call security sooner based on preconceived notions or beliefs. And so because of that, we track the gender, race and ethnicity of our patients involved in these events. I haven't been able to make any meaningful connections at this time, but we're still so early on, that we're going to continue to collect that data and see if there's some connections we can make.

And then as staff report events, we do on occasion find that there's culturally or racially insensitive comments that have been made towards staff. And for those cases, I'll again huddle with them. But I'll also huddle with the small group called our DEI Events Response Team, and that's our Diversity, Equity and Inclusion Events Response Team. And they can offer perspectives and considerations that I might not realize on my own, and they help in developing an approach for future interactions and also for supporting the staff members involved. They even offer peer support if the individual involved would appreciate that.

Host: Yeah. So Tatum, how has the staff at your organization, how have they responded to the interventions that have been put into place?

Tatum O'Sullivan: They verbalize that they really appreciate having somebody check in on them and reach out afterwards. They also like being involved in the discussion as to how to handle future interactions. One of the things that I've noticed on my own is that speaking with those involved also allows me to make a connection with them and helps to build relationships and trust, which is so important in what we do in risk management.

Host: You were talking about how you provide support after an incident. I would imagine that is very much appreciated by them. And I would imagine they appreciate the training and the deescalation techniques that you have taught them as well. So, I think that is great. Tatum, as we wrap this up, any final thoughts you'd like to share?

Tatum O'Sullivan: I wanted to thank the team at ASHRM for continuing to address workplace violence and to you, Bill, for allowing me the opportunity to share our approach. Last year, the Healthcare Facility Workplace Violence Risk Assessment toolkit was made available through ASHRM on their website. And it really helped me to identify gaps that I didn't initially consider. And so, I'd recommend taking a look at that if that's something that you have not already done. And then again, I wanted to thank you for speaking with me today and to wrap up by wishing the risk professionals a Happy Healthcare Risk Management Week, and thanking them for all those they do to keep those in their community safe.

Host: Well, Tatum, thank you for your time and sharing this great information. Like I said earlier, I know is beneficial to anyone listening to this and thank you for your thorough and professional work in this area. It certainly is appreciated. Thank you again.

Tatum O'Sullivan: Thank you, Bill.

Host: And once again, that's Tatum O'Sullivan. And join the American Society for Healthcare Risk Management in celebrating HRM Week, June 19th through the 23rd, 2023. This annual event held in the third week of June is the time to show your appreciation for healthcare risk professionals in your organization and your community. For more information, please visit ASHRM.org/resources/hrm-week.

The ASHRM podcast was 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 ASHRM.org/membership to learn more and to become an ASHRM member. And if you found this podcast helpful, please share it on your social channels and check out the full podcast library for topics of interest to you. I'm Bill Klaproth. Thanks for listening.