Codes of Conduct – An Approach to Reducing Workplace Violence

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Tom Haederle
In 2022, there was a physical assault, verbal abuse or threat issued every 38 minutes in a Massachusetts health care facility. That was a big leap up from one incident every 57 minutes in 2020. This frightening statistic prompted the Massachusetts Health and Hospital Association to release a report titled Workplace Violence at Massachusetts Health Care Facilities: An Untenable Situation and a Call to Protect the Workforce.

00;00;44;06 - 00;01;14;16
Tom Haederle
Welcome to Advancing Health, a podcast from the American Hospital Association. I'm Tom Haederle with AHA Communications. AHA's Hospitals Against Violence or HAV initiative, provides tools and resources to hospitals and health systems combating violence in the workplace and in the communities they serve. Today, three Bay State experts joined Laura Castellanos, associate director of AHA’s Hospitals Against Violence Initiative for a discussion of workplace violence and what can be done about it.

00;01;15;03 - 00;01;32;27
Tom Haederle
We're pleased to welcome Patricia Noga, vice president of clinical affairs with MHA. Bonnie Michelman, executive director of Police, Security and Outside Services, Massachusetts General Hospital, and Mass General Brigham, and Christi Barney, Vice President of Quality in Patient Safety at Emerson Health.

00;01;33;27 - 00;01;49;20
Laura Castellanos
Thank you, Pat, Bonnie and Christie for joining me. I do want to start with you. I know that the MHA created a health care safety and violence prevention work group. I just wanted to learn more about how it was formed and why.

00;01;50;19 - 00;02;21;07
Patricia Noga
So the MHA Health Care Safety and Violence Prevention Work Group was formed about six years ago by MHA issuing a voluntary call for interested parties to participate in a workplace violence prevention work group. And it was formed because about six years ago, many of our members began expressing concern about the increased incidence of violence in their health care organizations.

00;02;21;17 - 00;02;29;25
Patricia Noga
Now we have about 70 multidisciplinary members from 48 different health care organizations that are participating in our work group.

00;02;30;22 - 00;02;42;20
Laura Castellanos
That's outstanding. So tell me what relationships really made this possible to bring in so many different members and organizations to work on this common cause?

00;02;43;07 - 00;03;25;03
Patricia Noga
The relationships among the work group members have evolved over time. We have many different members: involved security and safety specialists, risk managers, quality and safety staff, human resources and nursing and other clinical professionals from our member hospitals and health systems. And the work has evolved into robust communication and collaboration, sharing and promoting best practices and industry standards, and also the establishment of baseline data and the ability to confidentially trend violence data over time.

00;03;25;13 - 00;03;34;10
Patricia Noga
We're really proud that our work has culminated in the production of MHA's Workplace Violence Report earlier this year.

00;03;35;00 - 00;03;53;02
Laura Castellanos
Outstanding report, which for the folks listening, there will be links added to the description. Let me ask you one follow up question to this work. Can you share with me what type of support you received from leadership, from governance, really helping advance this work.

00;03;53;19 - 00;04;23;22
Patricia Noga
Right from the outset, hospital CEOs were very supportive of our work and really have supported the continuance of us meeting on a bi-monthly basis. And of note, on an annual basis for three years in a row, we've been providing the CEOs with hospital specific reports of workplace violence in their specific organization and also trended in aggregate over the state.

00;04;24;05 - 00;04;33;01
Patricia Noga
So they can they can really learn what's happening in their environment and then take action to prevent future violent events.

00;04;33;25 - 00;04;52;03
Laura Castellanos
Thank you for that. Bonnie, I'm excited to speak to you today. Definitely an expert in this field. I want to talk to you about what you're seeing in your state. What types of trends around security issues for health care organizations should folks be aware of?

00;04;52;24 - 00;05;21;05
Bonnie Michelman
Thank you, Laura. We're seeing a lot. It is definitely not a job for the weak these days. We're seeing a large amounts of violence and conflict in our in our workplaces. And this is true across the country, and it's particularly true since the pandemic. There are more people that are disregulated. There are higher numbers of behavioral health patients often who cannot easily get into facilities that once they were able to get in before.

00;05;21;06 - 00;05;51;17
Bonnie Michelman
There are not enough facilities. There are not enough caregivers or psychiatric staff. We're seeing issues with cyber attacks to hospitals. We're seeing issues on protests and extremist groups, whether it be against transgender care, whether it be against people who provide abortion or reproductive health services. We're having issues as are many, many organizations and industries around hiring and recruiting, particularly in health care.

00;05;52;11 - 00;06;22;16
Bonnie Michelman
So that in itself is causing more fatigue around staff that is already tired and exhausted, both from the pandemic and from the acuity of the work that the amount of work our emergency departments are overflowing. There's people waiting in hallways for days sometimes to get either an impatient bed or to another facility and you know, liability for negligent and inadequate security.

00;06;23;09 - 00;06;39;29
Bonnie Michelman
Litigation is rising and people want to be safe and want to feel safe. And people want to work in places they feel safe. So there's a lot of things that are occurring that are definitely a challenge. I think we've made some good progress on that, but it's not easy.

00;06;40;28 - 00;06;59;21
Laura Castellanos
Definitely not easy, just focusing on the progress we have made. Can you share with us some security interventions or innovations that you're also seeing in the fields? You mentioned folks really coming together just because we're seeing a rise in this. So anything of note of that happening in the field?

00;07;00;10 - 00;07;28;02
Bonnie Michelman
Yes, I've seen huge improvements over the last several decades. I've been doing this work a long time. I've seen first of all, security people that are hired and credentialed and trained with certifications and degrees. I have seen organizations, hospital organizations that are looking at workplace conflict and violence as a major, a major objective and goal for the whole hospital, not just a clinical need or goal.

00;07;28;26 - 00;07;55;21
Bonnie Michelman
So it's really become part of the infrastructure. I have seen a lot of collaborative groups that have worked on proactive activities and initiatives to diminish and mitigate health care, conflict and violence. And again, a lot of it's conflict, it's threats and intimidation and harassment and stalking and bullying. Yes, there's some physical assaults as well, but that's minor compared to the the other kind of thing.

00;07;55;21 - 00;08;30;18
Bonnie Michelman
It may be a discriminative and hateful language and abusive language. And that can have a huge impact on someone, not just a physical assault. So having a really comprehensive workplace violence program, which includes a governance structure with one person owning it. Lots of collaborative groups working on it. Proactive activities, many of them that create of a real ability to diminish conflict and violence and then obviously good reactive strategies, great training and good metrics to measure the result of what you're doing as well.

00;08;31;16 - 00;08;53;15
Laura Castellanos
Now, thank you for that. Kind of staying on some of those key components to building a workplace violence prevention program or workgroup. What are what are some of the learnings you can share with us around training? You mentioned training. I know that there's a lot of questions from the field around de-escalation and what types of trainings folks should be looking to.

00;08;54;08 - 00;09;27;09
Bonnie Michelman
I think that's such an important question, Laura. And I think, you know, people think if you do active shooter training, that's enough. Active shooter training is important, but health care actually has the lowest amount of shooting shooters or active shootings in than any industry in the country. So what's much more prevalent, obviously, is violence and conflict. And that's the kind of training that you need to have, training that's dynamic, that's interesting, that's relevant, that people can relate to scenario based training so people can see situations that they encounter every day, whether it's a patient or a visitor that's very upset, getting into someone's face or whether it's someone threatening or whether it's someone that's starting to throw things or even get worse.

00;09;27;09 - 00;10;05;01
Bonnie Michelman
The training needs to be really understandable. It needs to be user friendly. A lot of hospitals now use E-training, electronic training to do some of this, and that's great. But high risk departments and staff such as those that work in front desk areas or emergency departments or psychiatric units or security staff need to have in-person training that really covers de-escalation stages of conflict.

00;10;05;14 - 00;10;31;28
Bonnie Michelman
Diversions, defense mechanisms, all of that. And it's we've seen correlated statistical proof that those people that have better and more intense training are not victims of conflict and violence nearly as much. So it is a critical thing that people take the time and invest in training and that hospitals have interesting, good, wonderful training programs that they use.

00;10;32;29 - 00;10;48;25
Laura Castellanos
Thank you so much for expanding on that. Christi, Let me ask you a few questions. You've been part of this journey. So share with us, you know, your process and around tracking and analyzing workplace violence at your organization.

00;10;49;12 - 00;11;19;02
Christi Barney
Well, thank you for the opportunity to share a little bit about this. As Bonnie was just describing, the work in an individual organization really involves multiple different components. Certainly, we think about wanting to equip the teams so the training becomes really essential. You want to really understand the events themselves. And, you know, as we sort of think about this, data really helps ground and shape the ongoing clinical experience.

00;11;19;02 - 00;11;46;28
Christi Barney
And good data helps us figure out where to deploy our resources. You know, all of us in health care right now are in a resource constrained environment. We have to be really thoughtful. The better data we have, the better we're able to do some of this prioritization. So, you know, again, in terms of the data collection, it's more than just understanding perhaps the name of the patient or visitor and the name of the staff people involved.

00;11;47;10 - 00;12;11;24
Christi Barney
But to then have a real standardized way that we're collecting all the other factors that help us really learn about where our vulnerabilities are within our environment, help us think about deploying resources to create better environmental controls. Back to the training again allows us to analyze whether or not our interventions to equip our teams are really working as they're intended.

00;12;12;07 - 00;12;34;20
Christi Barney
And ideally, the thing I love most is to create a standard response after any event so that we're really taking good care of our workforce. A standard response allows us to deploy emotional support resources to make sure that there's a standard debrief that's happening and that we learn all we can from some of these events that just don't go to plan.

00;12;35;10 - 00;12;52;15
Laura Castellanos
Thank you. I know lots of different journeys to try to collect some of this data. So important to making some of these decisions. But let's talk about when you were beginning to create this effort, what data was available to you and what steps did you take to improve that data?

00;12;53;03 - 00;13;28;21
Christi Barney
Oh, great question. You know, I think one of the end points was realizing that when it comes to workplace violence data, the sources that collect that data within a health care organization are usually multifactorial. So often you have the security teams and they're creating security reports, so they have a certain piece of the story. Sometimes your occupational health will also have OSHA-related elements and they will understand certain things about the workers that were impacted and probably the other big sources.

00;13;28;21 - 00;13;49;11
Christi Barney
Then the patient safety or the safety reporting data platform. One of the things that we realized early on and that became even clearer as we gathered together in Massachusetts through the MHA to look at our data is that when you only look at each of those components, you're missing pieces of the story or you're sometimes missing events altogether.

00;13;49;21 - 00;14;23;27
Christi Barney
And so only when we really created a process within our organization to make sure that we harmonize those those data points and bring all three of those sources together every month... and use that as our source of truth to then report out to MHA. Did we really get our hands around the data? That also created wonderful partnerships, a natural point where your security team comes together with your patient safety and your occupational health, and you're really thinking collaboratively from all of those really unique and important viewpoints on how best to address these issues.

00;14;23;27 - 00;14;31;13
Christi Barney
So that act of pulling those different sources together actually is also part of your solution and part of the way forward.

00;14;32;02 - 00;14;47;15
Laura Castellanos
Now, great exercise and thank you for sharing. I'm going to expand a little or ask you to expand a little bit on what groups came together. You talked about partnerships just from your within your organization. Can you talk about who wanted to be a part of this?

00;14;48;11 - 00;15;17;08
Christi Barney
Sure. You know, I think the workplace safety work within any organization is always enriched by the more disciplines you pull to the table. So certainly your security partners are an essential piece of this. Your frontline staff, so often that's your nursing leaders in different areas, your patient safety teams, you need providers involved. It helps to have representatives from the different areas who have specialty knowledge.

00;15;17;26 - 00;15;43;28
Christi Barney
It's good to have your IS teams involved so that again, your your data capture is working as well as it could. And sometimes you also need your facilities teams if you're thinking about environmental resources.  In terms of partnerships, we also created partnerships through this wonderful work group at MHA because we then, as Pat was explaining earlier, really brought together some of these different stakeholders and we learned from each other.

00;15;43;28 - 00;16;06;28
Christi Barney
I think if the pandemic helped us see anything, it was really the power of collaborating collectively and a chance to share and learn from each other. So, you know, often when we have a security question, we can turn to Bonnie and we can pull best practice from her expertise. We don't have to invent it ourselves. We really have this opportunity to share.

00;16;07;15 - 00;16;29;13
Christi Barney
That's been particularly true when each of the organizations has worked on things like code of conduct or policies and practices. Creating those sharing our documents together allowed us to again leverage the power of the whole and really think again about each of those different components to make sure that each of our programs was as robust as possible.

00;16;29;13 - 00;16;43;29
Laura Castellanos
That's wonderful. So let me ask you to give, I don't know, a takeaway or some advice for other health care leaders listening who are interested in creating a robust and comprehensive workplace violence prevention program. What advice do you have for them?

00;16;44;19 - 00;17;23;21
Christi Barney
Don't give up and work collectively. Really, you know, leverage, leverage your peers for support around this really essential work. I also think, again, because I'm the sort of data person on this particular discussion, I think we have to be good data stewards as much as we know that this is a huge problem in health care organizations, I think once you're really robustly collecting the data, there will be more data points, there will be more events, and probably the C-suite realized when they started and we want to capture that.

00;17;23;21 - 00;17;43;17
Christi Barney
We want to capture more of the verbal difficulties that people are having, the verbal abuse, the sort of agitation leading up to these actual events. And so I think one of the things that we had to do is prepare the board and prepare the senior leaders that initially you're going to see more and more reporting. And that doesn't mean that we're less safe.

00;17;43;17 - 00;18;12;09
Christi Barney
It doesn't mean that those great training programs aren't working. It means we're doing a better job at getting our hands around the scope of this problem. And once you're there, then you have this wonderful opportunity to dig deeply and realize that there is nuance and training that you might want for different populations, or that there really is appropriate moneys to be spent on things like communication devices or panic alarms or, again, whatever is needed in the particular setting.

00;18;12;18 - 00;18;28;20
Christi Barney
So I think as you go forth, bring partners and and make sure again that that you're letting the senior leadership team and your C-suite really understand that more is actually better at this point. If we really want to do right by our frontline teams.

00;18;29;16 - 00;18;55;10
Laura Castellanos
Thank you for that. I know we're still grappling with really understanding the full scope of this problem, so thank you for sharing that. But I actually want to circle back to you. Christine mentioned the code of conduct, and that's actually part of the reported shared in the links in the description of this podcast. But I want to take a moment to talk about the purpose and the expectations from the MHA in releasing this code of conduct.

00;18;55;26 - 00;19;31;22
Patricia Noga
Yes, well, the code of conduct was developed by a subgroup of our Health Care Safety and Violence Prevention Workgroup. People very interested in establishing it, and it is a unified code of conduct that the MHA, our Board of Trustees has endorsed and we are hoping that all of our member organizations will take that code of conduct and customize it to whichever way it works within their organized session as they are developing their own code of conduct and violence prevention policies.

00;19;32;02 - 00;20;02;12
Laura Castellanos
Thank you for that. Well, we're coming to a close, but, you know, this has been an outstanding conversation. So many great pieces of information and learnings share from this group. But I want to close this out with you, Bonnie. You know, you mentioned and gave us a great scope of trends and new interventions and innovation. Do you have a takeaway for our audience, something that will equip them as they take on creating safer workplaces for the health care workforce?

00;20;03;02 - 00;20;31;29
Bonnie Michelman
Sure. Thank you. I think that it takes a village. These issues are not going to go away and we have to get very robust the way we do with hand hygiene programs in our hospitals, the way we do with clinical safety. We have to get everyone involved. People have to understand the criticality. The data that Christy pointed out is so important to help us redeploy resources the right way because there are not unlimited resources.

00;20;32;09 - 00;20;56;10
Bonnie Michelman
The work we're doing in MHA, and I'm fortunate to chair that work group, is so important even with legislatively, so that people who assault people in health care may get higher penalties at some point in time, and that may be a deterrent. The code of conduct where everyone is seeing what is and isn't allowed in our in our health care organizations doesn't mean that it will be the end all, be all.

00;20;56;10 - 00;21;19;03
Bonnie Michelman
But it is another signal to people that they may not put us at risk. And what will happen if they do. So we have to get bold, we have to get tenacious, and we have to persevere, as Christi said, with all of this, because it is the way that we will keep our environment safe for our patients, our visitors and our staff.

00;21;19;03 - 00;21;20;20
Bonnie Michelman
And that's what we want to do.

00;21;21;05 - 00;22;03;13
Laura Castellanos
Thank you, so nicely said.  So thank you Pat, Bonnie and Christie, what a pleasure. We are going to be releasing this podcast during April's Workplace Violence Awareness Month, so we may continue to raise awareness and work together towards preventing violence. For more resources and tools, visit AHA’s hospitals against violence at www.aha.org/HAV. Thank you again.