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/membership to learn more and to become an ASHRM member.

I'm Bill Klaproth. On this episode, ASHRM Enterprise Risk Insights: Workplace Violence Prevention. And joining me is Dr. Thomas Campbell, Ann Curtis, and Dr. Jamie Elyse Malone as we discuss workplace violence prevention strategies within Allegheny Health Network and learn how a multidisciplinary approach is transforming safety for healthcare workers.

Dr. Campbell, Ann, Dr. Malone, thank you so much for your time today. I really appreciate this, which I know is going to be a great discussion. So, thank you so much for your time. Dr. Campbell, let's start with you and bring you in on this. Why is it important to report track and trend incidents of workplace violence?

Dr. Thomas Campbell: Thanks, Bill. I think it's important to track and trend and know the numbers that you're dealing with. If you don't measure something, it's hard to address it. So with measurement, you can see where your problems are and where to address them. You can also see if you're getting better and improving over time.

One other thing we found at Allegheny Health Network are there are many ways to report. We all know that incidents are way underreported. And so, it's important to find all of the different reporting tools that your organizations have. We found that some of the security reporting, incident reporting system, as well as employee health reporting systems, all had different numbers of reporting events and locations, and it was important for us to look at them as a whole. And we could then gauge what to go after as far as improvement areas, as well as are we making any successful attempts by our changes that we've made? And I think that was a really important lesson that we all learned as we got together and put our heads together about measuring, tracking, trending.

And as I mentioned also it, we all know that this problem is very underreported. And so, making an effort to improve easy ways for employees to make reports and to let them know it wouldn't be held against them, and that they shouldn't have to deal with violence and threats as part of their job, as some of them believe that's just part of work.

Host: Yeah, I think that's very well said. Know your numbers. That's really important. And the under-reporting really is a big factor. So, as you said, Dr. Campbell, coming up with easy ways to make reporting to increase the number of reports. As you said, incidents are always underreported. And Dr. Malone, let me ask you this then. Speaking of under reporting, how do you educate the staff to prepare them to manage workplace violence and maybe an add-on and to report it?

Jamie Malone: So, that all goes into the education piece. So, we know education is something we're told to do. So if you're a Joint Commission-accredited hospital, you're told to do education. That's part of the accreditation standards. It's also part of the OSHA guidelines. But more than that, we want to educate our staff because that's part of best practice standards in workplace violence prevention. We want our staff to know what the techniques are to help prevent and manage violence. We want them to have these tools in their tool belts on what to do when they do encounter these violent events. Because believe it or not, most people don't know what to do because they don't encounter this before they come into the workplace, unless maybe they worked in retail before healthcare. So, we want to prepare them. So, we have created actually our own education program. This is something we just actually recently went live with only a year ago, so we're really excited about.

We have a program called Crisis Response in Healthcare. Our full program, our initial program is about eight to eight and a half hours. It goes over prevention, it goes over management, but it also goes into a deep dive of not only our mission, vision, and values, but our policies, our procedures, our reporting, it's very AHN-focused, which is the nice thing because a lot of health systems have vendor-provided education. And while that's great, it gives you those tools and deescalation and all that, we were able to really specify this around our practices at AHN. And so, it really meets our needs at AHN.

In addition to that, we can go over things that are very healthcare-specific and focused. Things like creating therapeutic relationships and therapeutic communication with our patients, deescalation techniques specific to healthcare, trauma-informed care. Unfortunately, that's a huge thing within healthcare and something we do have to be very cognizant of with our patients. And unfortunately, sometimes we do get to the point of having to restrain patients. So, we need to teach our staff how to do that as safely as possible. And of course, the things like only doing it as a last resort and least amount of time and all those best practices and physical restraining techniques.

And then, the considerations of, well, if it is a patient, you have to consider what if they do have a medical condition? They're in the hospital, so we need to make sure we're teaching them how to do it safely. And then, we're going to talk about environmental considerations as well later on. But we also go into environmental considerations in the hospital setting. So, it's a very widespread comprehensive program, very specific on what we do within healthcare. However, we recognize that maybe not every single individual within our network and enterprise maybe need that comprehensive education, so we also have a lot of additional education on top of that. We have e-learning modules in our learning management system, we actually have that program available. We call it the verbal portion of that program where they don't do the physical skills, so they don't do the physical restraining skills that we're able to offer through virtual classes. So, we have a lot of different levels of education also available for maybe employees who don't need that full program. So, we try to take a very comprehensive approach to our education.

Ann Curtis: I just wanted to add on with what Jamie said. And she's spot on with our education. And I think one of the great things about the education that we provide is we also do the education from a team approach. So, we have, you know, our first responders from the security and police perspective training along with our clinical staff, and we found that that really helps to build teamwork, because they're working together in those situations. And it also helps build those communication skills, which is also very beneficial when those occur.

Host: Yeah. Education is so important. I think a lot of healthcare workers probably think, "Oh, this is part of the job. Somebody spoke bad to me. Somebody just spit on me. Just another day at the office" where education, letting them know that, "Hey, this is not okay, and this is how you report it." So Dr. Malone, you said you set up the crisis response in healthcare. It's an eight-hour program of education, and then you listed many other programs to educate the healthcare workers on what to do in these situations. Would that be right?

Jamie Malone: Yes.

Host: Yeah, really important. So, education, a big part of this. And then, Ann, we live in a technological world. There's so many things out there. You hear of AI this and AI that and so many other ways that we can use advances in technology to help us with many aspects of the workplace. How do you leverage technology advancements in preventing workplace violence?

Ann Curtis: So when it comes to technology, we have definitely added different devices, different technology methods across the board. We initially started off with metal detectors and x-ray scanners at our emergency department entrances. However, as we all know, hospitals have a number of additional entrances to gain access. So, we've actually been expanding and including metal detection systems at additional entrances at our hospital locations. And the product that we chose for that is one that gives very high throughput, so a number of people can walk through very quickly while it's doing that scanning mechanism to detect for any weapons.

In addition to that, we have also standardized across the board at all of our hospitals by utilizing the exact same enterprise platforms. So, all of our camera systems are the exact same across the board. We have standards that we implemented at our hospital locations where depending on the type of unit or department or area, we have a standard of what we require as it relates to those environmental strategies. So, we have locations where we require a certain number of cameras, certain camera locations, so that way we have that view with those cameras. In addition to that ,also panic alarms, very strategic panic alarm placement that we have as well as card access. So, we have some areas that are restricted, that are locked down, where only those employees that have access on their badge can enter, or in some cases exit. So by establishing those standards, we have those implemented across the board at all of our locations.

And we also have our enterprise security operations center. So, we like to call that our homegrown 911 center, and that center is staffed 24/7 by professional dispatchers who are constantly monitoring all of the cameras at all of our locations, as well as dispatching police security for any incidents. And the great thing about that is if they receive like a panic alarm notification, they know exactly which cameras to pull up in that area. They can give real, you know, live, right at the time updates to those that are responding. So, that technology really helps us keep everybody safer, and that's something that we're continuing to improve.

Jamie Malone: Just quickly to add on to what Anne said, because what we do within our healthcare system is so important, but we also leveraged our electronic health record to help us as well including adding things like a standardized way to document our crisis responses, a standardized way to document if somebody did encounter violence during that admission.

We also have a way to document behaviors that we might see from the patient and they're from evidence-based tools that help to predict if the patient is about to become violent. And we don't want to overly rely on these tools. We do still need to use critical thinking to know if that patient truly is about to become violent, but that's predictors to help us know if we maybe want to take certain interventions to help prevent that violence from happening. So, we have all these tools available within our healthcare or electronic health record.

In addition, we also have flags now established based off those tools. So if that patient is at risk for becoming violent, a banner will pop up. We also have a banner that will pop up if they do have that recent history of violence, if they were violent during their admission. And we're actually working on a long-term flag. So if somebody was highly violent or repeatedly violent, we'll actually have a system set up where our leaders within the health system actually can put a long-term flag that will cross over encounters, so we can see it both in our inpatient spaces and outpatient spaces. Because unfortunately, we know the best predictor of violence is that history of violence. So, we do want our staff to be aware just so they have that extra indicator and can just keep themselves safe if that person does become violent again.

Host: Yeah. Using the EHR with those early predictors or flags, as you said, Dr. Malone is really a good idea to give you insight potentially before something could happen and loved all the things that you've put in place because it's not just the patients that could exhibit violent behavior. You've got potentially family members bringing things into the hospital, guns, knives, et cetera. So, that's another component of this as well. And then, on the flip side of this, Anne, how have you integrated and prepared the police officers to work in a healthcare setting?

Ann Curtis: So, we actually implemented our Highmark Health Police Department at our AHN Hospitals in 2018. So, we're approximately seven years into this program. And when we started, we took it from the standpoint of hiring police officers, policing on the street or in a municipality is completely different than policing in a hospital.

In the hospital, we have people who are going through very stressful times, very stressful situations. So, we understood that that approach was going to be different. So, we actually have our new hire police officers attend a three-week training session prior to starting work at the hospital. And during that three-week training, we go over a number of different healthcare-specific items, and we talk about from the regulatory standpoint. Because policing, as I said, in a hospital is different when those law enforcement tools are going to be utilized.

We also talk a lot about patient experience. We also go through different scenarios and, in some cases, some simulation where we're talking about different events, that they may be responding to, the different types of situations that they're going to be encountering. And understanding that when we're referring to the term clinical staff, we're actually talking about everybody that's taking care of the patient, which includes our police officers. So, they work very closely partnering with the clinical staff. In addition on the education that Jamie had talked about, our crisis response in healthcare. We have them attend that once they start working at the hospital. And that really helps them get to meet the staff, get to work with the staff, and really build those partnerships. But we want to make sure that that training that they're going through, in addition to the law enforcement specific training, we do a lot really focused specifically around healthcare and understanding the difference in that environment and how the policing in that environment should be done. So, it's very much focused within that initial training.

Host: So, you send the police officers through the crisis response and healthcare training as well, just so everybody's on the same page then, would that be right?

Ann Curtis: That's correct. What we've actually seen is it really helps in building that teamwork, Because we may have situations where we have a patient that's maybe upset with clinical staff, you know, maybe they received a bad diagnosis and that person may be sort of escalated on the behavior side. And a lot of times what we found is, you know, if our police officer or a security officer is the one stepping in, a lot of times they can really help verbally deescalate that person because they're not coming in from a medical standpoint. They're coming in differently. So, they're able to really talk and communicate with that person and understand. And so, put a lot of focus on that verbal deescalation and on that communication.

Host: Absolutely. And Dr. Campbell, how do you support your staff after an incident of workplace violence?

Dr. Thomas Campbell: We have multiple ways of responding to workplace violence. We have some immediate responses as Ann and Jamie had explained. We have some rapid responses. We have teams that have been specially trained, CISM teams as many have done across the country are part of what we're training to do, but we also have internal expertise within our behavioral health units that are there to respond after the fact, as well as people might come in and have some delayed response to the violence that happened.

And a third way we have is with external vendors we use with our EAP and outside help who are there in case someone feels uncomfortable using internal people for their help. Even though we understand that probably internally people understand well, some people are reluctant. So in order to get people the help that they need in the way they can, we have internal mechanisms, external mechanisms, rapid response for the event, and then follow up after the event. And I think that's critical.

One other point that I'm going to ask Jamie to jump in about is that we're also training staff to look for signs and symptoms in our employees that may not show up immediately, but may show up after a violent event and they could reach out and try and get them the help that they need. Jamie, can you add?

Jamie Malone: Absolutely. Thank you so much. So, we're really focused on employee wellness right now, and having Dr. Campbell is so important in that. I'm also helping with some additional education programs around employee wellness. So, two additional education programs that we're bringing in. One is from the American Foundation for Suicide Prevention to make sure we're taking care of our healthcare workers. Because unfortunately, healthcare workers do die by suicide at higher rates than the general population. So, we need to make sure we're taking care of them and know those signs. So, we brought in their program called Talk Saves Lives. And then, that's only a one-hour program. So, it's very succinct and easy to go through. It's very quick.

And then, we're bringing in a more comprehensive education program called Mental Health First Aid. It's a very well-renowned program from the National Council of Mental Wellness, I believe it is. And Mental Health First Aid is a program where instructors, it takes three days to train the instructors. But for the students, it's about an eight-hour class as well, and it goes over so many great basics. It goes over different mental health conditions, signs and symptoms, signs of a crisis, how to assess and go over an action plan of what to do for people when they do reach that point. And of course, that's going to benefit us as clinicians and healthcare workers for our patients, but we're actually bringing this in specifically so we can help ourselves.

So if I'm a leader and I see that one of my employees or one of my staff members are struggling, what can I do to assist them? If they just had a really bad workplace violence event two weeks ago, and now I'm seeing signs like they have increased med errors and tardiness, and I'm seeing those signs of maybe some post-trauma symptoms, what can I do to help them and support them after that instance?

So, we're really excited to be bringing in these programs. We're kind of in those initial phases, so we don't have a lot of outcomes on what's going to happen with them, but we're just so excited to be able to offer these wellness initiatives for our frontline staff.

Host: Thank you, Dr. Malone. I appreciate that. And Dr. Campbell, and for all of you really, just to comment here, all of these initiatives that you're doing, this really helps with staff morale, right? I mean, this helps with retention as well, which is another thing in the industry we talk a lot about. And ultimately, this produces better health outcomes because the staff is functioning well because there's a positive workplace environment. Dr. Campbell, would that be right?

Dr. Thomas Campbell: Bill, I wholeheartedly agree with that. We know that burnout and wellness are related to a feeling of safety and security. And certainly, by addressing these issues, we are providing a safer workplace. When people are safer, they have less burnout, and we know less burnout, causes less anxiety, and better patient care. So, it's extremely important that we focus on violence and wellbeing of our employees and know that some of the basics of people feeling safe where they work is critical for them to stay. And as you said, if they're happy, they're in a community where hopefully we've emphasized today that interdisciplinary collaborative efforts that we've had in order to do this, it builds community as well. And I think when you have community, people are less likely to turn over their jobs and stay because they're happy where they're at. And with this topic, they also feel safe in that people care about them where they work.

Host: All great points, and that's why a discussion like this is so important. So Dr. Malone and all of you, please feel free to chime in. Thank you for sharing this great information on what you've done at Allegheny Health Network. For another healthcare organization that wants to adopt similar strategies to protect their frontline staff, where would they start? Can you give us some basic tips that someone listening to this could use to enhance their workplace violence prevention strategy?

Jamie Malone: Yeah. So, I can start, but I would love to hear what my other panelists have to say. So, engaging key stakeholders and leaders. Having leader buy-in is going to be essential. So really emphasizing why this work is so important if you don't have that currently is going to be key. But also following what Dr. Campbell just said and having that interdisciplinary or multidisciplinary approach. I mean, just look at us on this podcast. We have a physician, a nurse, and somebody from our corporate security department. So, we have three key stakeholders from three key areas to address this issue. So, having key stakeholders from across your enterprise is going to be so important, and taking this from different levels is going to be so important. And collaborating, it's going to be so important to tackle this issue because if I just took this issue from just a nursing perspective, I wouldn't get that far. Maybe I could do initiatives that just impact my nursing teams, but I wouldn't be able to create these widespread projects and programs that do truly impact us as a healthcare system.

Ann Curtis: And if I could add on to what Dr. Malone said, and I wholeheartedly agree about that multidisciplinary approach is also making it a priority. And that's something that we did. And even going back to what Dr. Campbell was talking about with reporting, that is how we found out that we had so many different reporting mechanisms for people to report those incidents of workplace violence. So when you're just looking at one reporting mechanism, you're not getting the full view of everything that's happening. And I think us making this a priority, also each talking about from our perspective as it relates to workplace violence, things that we're seeing, also information that we have that we shared with each other, I think that definitely helped benefit us in establishing programs and establishing trainings, education across the board to really address this issue.

Host: Yeah. Dr. Campbell, could you chime in as well?

Dr. Thomas Campbell: Absolutely. I maybe we will end where we started, and as Anne pointed out that measurement and reporting is really, really key to having a program and having success. And when I say reporting, it's not just to our system leaders, but also to the frontline staff, what is being done to keep them safe and secure. And I think that communication is critical.

And as these guys pointed out, having a community and involve as many people as you can and efforts to reduce workplace violence is critical. We need to hear the needs of our outpatient areas compared to our large hospital settings. We need to hear some new challenges with the virtual world we live in and how some of our staff are threatened and abused virtually, and how to address that. So, I think we wouldn't know those things if we didn't involve all the many people that we can and be as collaborative as possible.

Host: Yeah. I love all of what you had to say, that collaborative aspect of it, Dr. Campbell, and you said, make sure you make it a priority. And Dr. Malone, you have to get that leader buy-in. That's really important as well in the multidisciplinary approach with all the key stakeholders. Well, this has really been a great discussion. I have appreciated talking with each and every one of you. Thank you so much for your time. Before we wrap up, I would love to go around the room and just get any final thoughts from each of you. Dr. Malone, let's start with you. Any final thoughts?

Jamie Malone: So, I want to echo what Dr. Campbell just said and being very transparent with your results. It's going to help a lot with that frontline staff buy-in. It is so hard sometimes to engage your frontline staff as a leader if you happen to be a leader listening to this. So, being super transparent on your numbers, which can be scary because sometimes your numbers don't look great, but also your initiatives and what you are doing to prevent workplace violence. Getting their buy-in, getting their perspective, surveying them, getting them engaged in councils and community is going to be really important to help you nudge those numbers down. So, getting that frontline staff involved and being transparent in your work is going to be really important.

Host: Yeah. Great thoughts. Thank you, Dr. Malone. Anne, how about you? Final thoughts?

Ann Curtis: Echoing, of course, exactly what Dr. Campbell and Dr. Malone said, and also when it comes to getting that frontline staff engaged, having those local committees as well where they can see the results, they can get involved, they can provide feedback, they can also bring up those issues, that also is extremely helpful.

You know, with it being April and being Workplace Violence Awareness Month, that's one of the things that we found in getting staff's feedback and what staff are interested in, was very key in planning the activities. We scheduled for this month for everyone throughout our entire network. And it was based on topics that they were interested in, topics they wanted to hear about. That really helped us put those activities together to put that information out to everyone.

Host: Yeah, well said Anne. Thank you for that. And Dr. Campbell, wrap it up for us. Final thoughts from you?

Dr. Thomas Campbell: Just a little different then to wrap it up is not to forget your legal team as well as your legislative advocacy folks at your health systems because we can't do it all on our own. So, we need to make sure that there are laws and legislation that help protect our healthcare workers outside of our organizations that can help us with all of these efforts.

Host: Very well said. Dr. Campbell, Ann, Dr. Malone, thank you very much for your time. This has really been informative. I really appreciate it. Thank you again.

Dr. Thomas Campbell: Thank you.

Jamie Malone: Thank you.

Ann Curtis: Thank you.

Host: And once again, that is Dr. Thomas Campbell, Ann Curtis, and Dr. Jamie Elyse Malone. And remember to support workplace violence prevention initiatives throughout healthcare. And for more information, please visit ashrm.org/membership to become a member, and the ASHRM 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. Thanks for listening.