The Joint Commission ECNewsMarch 2014 Volume 17 Issue 3 Environment of Care Emergency Management Life Safety

OSHAOSHA & Worker Safety Engineering Solutions to Workplace Violence Prevent workplace violence via safety-enhancing design and equipment

health care organization is a stressful and potentially volatile work environment—a fact that’s no secret to A anyone who works there. Many factors contribute to the volatility. Patients and family members, especially those fac- ing emergencies, are in distress. They often encounter long waits in crowded waiting rooms. Some may be under the influence of alcohol or other drugs and/or suffering from untreated acute or chronic mental illnesses. Some may be carrying weapons. Gang fights can spill over into emergency departments. And the sheer volume of people—staff, patients, family members, and visi- tors—coming and going at all hours creates an overall unpre- Health care organizations must take steps to prevent violence. dictability. These conditions make health care workers vulnerable. Inside Studies indicate that a substantial percentage of hospital staff 2 Test Your Standards IQ have been physically assaulted at least once during their careers.1 And, according to the latest Bureau of Labor Statistics reports, 5 Effective Maintenance and Testing Protects Life Safety the total number of nonfatal injuries and illnesses resulting from Progressing further into EC.02.03.05: EPs 5 and 6, workplace violence increased for the private sector in 2012. Testing notification devices and no-flow fire pumps Meanwhile, also in 2012, the health care and social assistance 8 Menacing Meds sector has seen a 6% increase, to 19,360 cases.2 How to safely manage hazardous drugs in the health care (continued on page 3) environment Engineering Solutions to Workplace Violence Workplace Violence: Tools for Engineering It Out (continued from page 1) Such trends command the attention of Architectural adaptations that can be made to existing floor plans the Occupational Safety and Health • Closed-circuit television monitoring and video recording of high-risk units Administration (OSHA). “Our mission is • Electronic access controls for emergency treatment areas to protect the American worker,” says • Metal detectors—installed or handheld, where appropriate—to detect guns, Mary Hoye, area director of the OSHA knives, or other weapons • Enclosed nurses’ stations, deep service counters, or bullet-resistant, shatter- office in Springfield, Massachusetts. proof glass in reception, triage, and admitting areas or client service rooms Among other duties, she coordinates • Employee “safe rooms” for use during emergencies workplace violence (WPV) activities for • “Time-out” or seclusion areas with high ceilings without grids for patients who the New England region. OSHA defines “act out” • Separate rooms for criminal patients WPV as any physical assault, threatening • Comfortable client or patient waiting rooms designed to minimize stress behavior, or verbal abuse occurring in the • Locks on counseling rooms, treatment rooms, staff bathrooms work setting. • Efficient closers on doors (shouldn’t be too slow) “It troubles me that many health care • Bright, effective lighting, both indoors and outdoors • Minimal furniture, arranged to prevent entrapment, without sharp corners or workers accept WPV as part of the job,” edges and affixed to the floor, if possible says Hoye. “Thus, they may ignore esca- • Limited number of pictures, vases, or other items that can be used as weapons lating behavior. I’ve also been shocked at Alarms systems/other monitoring/response devices the level of violence: bites, whiplash from • Panic buttons (at nurses’ stations, triage stations, registration areas, hallways, hair pulling, a face smashed against a nurse lounge areas) concrete wall, a stab with a full hypoder- • Handheld alarms or noise devices • Cellular phones, especially for home-health workers mic needle. It’s disturbing to see this in a • Privatechannel radios setting whose mission is healing.” • Curved mirrors for hallway intersections or concealed areas The facts are that some people have conditions or histories that prompt aggression, and family members may be aspect of the built space or any device during a WPV event if people have not experiencing anxiety or despair over the that removes a hazard from the work- been properly trained and are uncertain condition of a loved one—all risk factors place or creates a barrier between the about what they’re supposed to do,” says for violence. Health care workers must worker and the hazard. When preparing Hoye. “In addition to training, a compre- protect themselves while also being sensi- for new construction, a team of archi- hensive WPV program includes appropri- tive to patients. It’s a delicate balance tects, planners, and direct-care staff can ate reporting and record keeping. that requires a systematic approach to create spaces that eliminate or reduce “Because many health care workers prevention and appropriate consequences security hazards, merging knowledge of accept violence as part of the job, when for violence. design, materials, and hardware with something happens, they take care of needs and objectives of each unit or area. it—but then they don’t mention it to A comprehensive approach Planners still have many options for anyone,” Hoye says. “But if they do “OSHA likes to see a comprehensive enhancing worker safety (see “Workplace report it, it can become part of the approach to any workplace hazard, which Violence: Tools for Engineering It Out,” record, and others can learn from it. The involves a three-tiered hierarchy of con- above).3 organization can also track patterns.” For trols,” Hoye says. These three tiers are as example, Hoye notes, an organization follows: Administrative tactics may see that when the waiting room is • Engineering controls After applying appropriate engineering very crowded, WPV is more likely and • Administrative controls controls, the employer should consider then in turn make changes in the waiting • Use of personal protective equipment administrative controls, such as proce- room. In this way, controls on the dures, training, and maintenance. “Orga- administrative level feed back into engi- Engineering away the harm nizations may have engineering controls neering controls. “Engineering controls” refers to any and procedures in place, but they may fail (continued on page 4) www.jcrinc.com EC NEWS March 2014 3 Engineering Solutions to Workplace Violence Practical Solutions to (continued from page 3) Violence Risks: Two Personal protection Examples When administrative controls and engi- neering controls aren’t enough, the Mary Hoye, area director of the employer should choose to equip staff OSHA office in Springfield, with appropriate personal protective Massachusetts, coordinates equipment. In the case of WPV, exam- workplace violence (WPV) activities for the New England region. Hoye ples are bite-resistant sleeves or body offers two examples, gleaned from armor, which may be needed in special- OSHA inspections, of practical ized settings such as prisons or juvenile solutions to mitigate some common detention centers, where the potential for Staff should be able to signal for help. risk situations: violence is extremely high. • Working alone. In one residential “I bring up these options at trainings “Practical Solutions to Violence Risks: health care setting, staff members often worked alone, and they had so people will know about them,” Hoye Two Examples,” right). no way to summon help if a says, “though there are limits as to where violent situation arose. The such items might be used”—a point that Down to basics employer agreed to install panic illustrates the next lesson. If an organization can implement only alarms that allowed for rapid, one engineering control to make work- reliable response. So although the workers were still alone, they had A custom-made approach ers, patients, and visitors safer, it should a means of summoning help. As The Joint Commission emphasizes in be a system for communicating a WPV • Seeing what’s coming. In one all areas of the environment of care, and emergency, says Hoye. Whatever the sys- hospital, a patient waiting in an as Hoye reinforces, there’s no one-size- tem is—customized to the needs of the emergency department examining fits-all approach. What’s needed in a facility—it should have two components: room attacked a provider as she prison or a large inner-city hospital will • People must be able to signal for help entered the room. The engineering response was to likely not suit a small rural hospital or a when and where they need it. replace solid doors with opaque home health facility. An example: One • Those who receive the signal should ones, maintaining privacy but safety measure often suggested for hospi- know how to respond. allowing the provider to see where tals or mental health settings is minimiz- Some alarm systems are stationary; the patient is in the room before ing the number of loose objects available others are designed for workers to carry entering. “These were fairly simple solutions and bolting furniture to the floor to with them. Some are silent, while other that made a big difference,” Hoye prevent such items from being used as are audible. A loud noise can deescalate a reports. weapons. But this advice would not suit situation, but choices have to be consid- a home health setting, where one treat- ered in the context of the particular ment objective is to provide a cozy and organization. The bottom line is to make out rebuilding the whole facility,” says family-like atmosphere. sure employees are trained to use the sig- Hoye. “It begins with understanding “We like employers to have a written nal system or panic button and to under- one’s own workplace.” program for WPV that grows from a stand its meaning. That is, “If the alarm Engineering controls need to be main- risk-hazard analysis,” says Hoye. “In such system is activated, what do I do?” tained, of course. Alarm systems must be an analysis, a team made up of employ- If an organization is in a position to tested periodically. Key card systems ees, management, and representatives implement additional engineering con- must be monitored so access to private from a variety of departments (security, trols, Hoye recommends well-designed areas is appropriately limited. Burned- HR, legal, clinical, and so on) identifies workstations, lockable staff bathrooms, out light bulbs must be replaced the most vulnerable areas and the most and small, comfortable waiting rooms promptly. And if there are physical appropriate controls for the facility.” She with minimal noise and minimal waiting changes in a facility (for example, new offers two examples of practical controls, time to help reduce stress. “Organiza- construction, reconfiguration of depart- gleaned from OSHA inspections (see tions can do these kinds of things with- (continued on page 11)

4 EC NEWS March 2014 www.jcrinc.com Engineering Solutions to Workplace References Violence 1. Joint Commission Resources. Violence This article was developed through the (continued from page 4) code reload, Environment of Care News. 2013;16(11):6–8. cooperative efforts of the OSHA/Joint ments), the security systems must be 2. US Department of Labor, Bureau of Labor Commission Resources Alliance. reevaluated and adapted to those changes. Statistics. Nonfatal occupational injuries and ill- nesses requiring days away from work, 2012. “With any engineering control, you Accessed Jan 17, 2013. http://www.bls.gov need associated training so staff know /news.release/pdf/osh2.pdf. why you’re doing this, how it works, and 3. US Department of Labor, OSHA guidelines for how they’re supposed to respond,” says preventing workplace violence for health care & social service workers. OSHA 3148-01R 2004. Hoye. “That’s why OSHA emphasizes Accessed Jan 29, 2014. https://www.osha.gov the idea of comprehensive plans.” EC /Publications/osha3148.pdf.

Test your STANDARDS I Q The Answers

Here are the answers to the questions on page 2. How did you do? 4. A, true. Standard LS.02.01.34, EP 2, requires the location of the master fire 1. B, at least 18 inches. Automatic sprinkler systems are designed to cover a alarm panel to have either of the following characteristics: wide area when activated. To ensure proper flow from each sprinkler head • A protected area that is continuously occupied. Such an area would and sufficient coverage of a particular area, you must maintain an 18-inch have 1-hour fire-rated walls and ¾-hour fire-rated doors. plane of space below a sprinkler deflector—the plate on the sprinkler head OR that disperses the water across a specific area. • An area with a smoke detector. Note that perimeter (or wall) shelving units can extend to the ceiling as long This EP does not require an organization to build a protected area if it does as they are located against an existing wall and not directly under a sprinkler not already have one. Organizations can choose to put a smoke detector head. Wall shelving units serve as an extension of an actual wall. Since the near the alarm panel to satisfy this EP’s requirements. sprinkler does not need to reach an area behind the shelving unit, these units STANDARDS REFERENCE: LS.02.01.34, EP 2 are allowed to extend to the ceiling. STANDARDS REFERENCE: LS.02.01.35, EP 6 5. D, all the above. An Emergency Operations Plan should address the “who, what, where, when, and how” of an emergency, outlining an organization’s 2. B, false. Although Standard EC.02.05.03, Element of Performance (EP) 4, plans for mitigation, preparedness, response, and recovery. Basically, the requires organizations to provide emergency power for elevators, it does not EOP helps frame an organization’s emergency response and ensures a state state that every elevator in a facility must be tied to emergency power. The of constant readiness for potential disasters. EP does require emergency power for at least one elevator for According to Standard EM.02.01.01 EPs 5–7, these are some key elements nonambulatory patients. to include in an Emergency Operations Plan: The standards leave it up to each organization whether to put all elevators on • The organization’s processes for initiating and terminating the response emergency power. You should make the decision based on the results of a and recovery phases of an emergency, including under what well-considered risk analysis that examines the pros and cons of every option. circumstances these phases are activated. STANDARDS REFERENCE: EC.02.05.03, EP 4 • The individual(s) (usually indicated by title) who has the authority to activate the emergency response. 3. D, annually. EC management plans offer a high-level view of how a hospital • Alternative sites for care, treatment, and services that meet the needs of manages its facilities and ensures the existence of a safe and secure the organization’s patients during emergencies. environment of care. Hospitals must evaluate their EC management plans STANDARDS REFERENCE: EM.02.01.01, EPs 5–7 EC every 12 months, reviewing the plans’ objectives, scope, performance, and effectiveness. This review ensures that the plans remain current, relevant, and useful. To facilitate the annual review, consider designing your EC management plans with the review process in mind. While not necessary, this approach will make the yearly effort more effective and streamlined. STANDARDS REFERENCE: EC.04.01.01, EP 15

www.jcrinc.com EC NEWS March 2014 11