Mitigating Workplace Violence at Ambulatory Care Sites

Healthcare organizations often overlook the security needs of freestanding clinics and offices. These best practices will help you address the risks.

The Occupational Safety and Health Administration (OSHA) has identified healthcare workers as being among the highest risk groups for workplace violence, but most of the attention up to this point has been on hospitals. Freestanding site healthcare workers also have this risk, and it may be somewhat elevated because police or security officers are not routinely assigned to these locations. A lack of public perception of security issues compared to hospitals may also be a factor.

Unfortunately, placing a dedicated protection officer at every site where a violent episode might occur is cost prohibitive. We at St. Luke’s estimate it would cost our organization more than $5 million per year if we provided a security officer at every one of our ambulatory care sites where there is the potential for violence. Reductions in patient care service reimbursements paid by insurers to healthcare organizations in recent years have made it difficult to afford adequate security staffing even on hospital campuses, let alone offsite facilities.

Certainly, regularly providing an officer at some locations is justified based on the results of proactive threat assessments, but the potential for violence could escalate at any freestanding clinical site for any number of reasons (see sidebar).

Healthcare organizations should perform proactive threat assessments of all freestanding patient care sites, completing those with the highest service related risks first. In our experience, the following patient care services have had an increased risk for violence; some services may seem more obvious than others:

  • Outpatient Behavioral Health
  • Substance Abuse Rehabilitation
  • Pain Management
  • Occupational Medicine
  • Urgent Care Centers
  • Community Care Clinics
  • Orthopedics
  • End of Life/Palliative Care
  • Family Medicine
  • Neurology
  • Oncology/Cancer Treatment
  • Cardiology
  • Blood Drawing Stations (due to low staffing and their operating hours)

Situations that Could Prompt Violence at Offsite Healthcare Facilities

  • Medication abuse/drug seeking behavior
  • Unfounded malpractice accusation
  • Grief reaction/blame for family member’s death
  • Unresolved chronic pain
  • Pre-existing behavioral health issues
  • Clinical findings negatively affecting disability claim
  • Clinical findings adversely affecting patient’s employment
  • Billing disputes/inability to pay
  • Mandatory reporting requirements (suspected neglect and abuse)
  • Care of the under-privileged
  • Patient involuntarily discharged from practice for cause
  • First visit of a patient with extensive criminal history
  • Perception that caregivers are easily intimidated
  • Decreased perception of security compared to a hospital
  • Patient and/or family member inability to cope with stress

Violence Mitigation Strategies You Should Adopt
Freestanding patient care facility security plans are often developed in response to specific situations, but there are universal mitigation strategies that should be considered for most locations before an incident occurs. These are:

  • One public entrance, with a camera recording everyone who enters. All other building entrances are secured or have controlled access.
  • A barrier exists between receptionists and patients
  • Access to the treatment area from the waiting room is controlled
  • Examination tables are positioned in rooms so that patients are never placed between a caregiver and his or her escape route
  • Sharp objects are secured and out of patient reach in treatment rooms
  • At least one secure-in-place room has been identified
  • Emergency escape plans are rehearsed by staff
  • Panic alarm buttons or wireless personal alarms are available
  • Violence prevention and response education has been provided

Since violence prevention education can encompass many subjects, listed below is what we include in our freestanding clinical site security education program:

  • Identification of at risk clients
  • Early warning signs of aggressive behavior
  • How to avoid inadvertently escalating aggression
  • Differences between customer dissatisfaction and inappropriate anger
  • Simple aggression de-escalation techniques
  • Trusting your instincts as to the potential for harm
  • Proactive notification of police (no permission needed)
  • Police discretion – police don’t always have to arrest
  • Pre-staging “bad news” discussions with patients
  • Identifying secure-in-place locations and safe rooms
  • Fundamental response to an active shooter situation

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