March 16, 2023 TMIT High Performer Webinar Transcript

Workplace Violence II
Beyond Physical Harm – Systems Issues

March 16, 2023

Speakers and Reactors:

Dr. Charles Denham – Moderator
Dr. Casey Clements
Assistant Chief Vicki King
Chief Bill Adcox
John Nance, JD

Dr. Charles Denham: Welcome to our Workplace Violence Number II, our 201st webinar.  And this is the second part of a two-part series.  I’m Dr. Charles Denham.  I’m chairman of TMIT Global, and I’ll be the MC.  Today, we’re thrilled to have some terrific recorded sessions, and we have two great gentlemen to be reactors today as well.  And this is a second part of a two-part series.  And what I thought I would do is show a videotape that we think is just terrific.  This was generated by the Emergency Nurses Association for whom we have a terrific amount of respect and who have been very helpful to us and real champions of care at the front line.

We need to make it publicly known what is happening to nurses.  We get kicked and punched and cussed at, and we’re expected to just keep a smile on our faces.

Patients and their family members are so raw, they may be very angry.  They may lash out at you.  Some days, you just kind of feel like a punching back.

Over the ten years I’ve been a nurse, the environment has become more aggressive.

We’ve come so far that every one of our rooms here in our emergency department has a sign that states it’s a crime.  Assaulting or threatening behavior will not be tolerated.  It’s getting difficult sometimes to keep smiling,

Especially if a patient comes to you and they’re yelling at you, or they’re upset because it took longer for me to give them pain medication than it should have.  But you can’t say to that patient, Hey, I was just trying to save someone’s life next door.

Our society does not value what it takes to take care of someone.  I feel like they feel entitled that a nurse is here to serve them.  And I think that’s maybe where the problem starts.  We’re here to help you.

Every time you take care of a patient, you’re trying to give something from yourself.  You’re trying to give respect and kindness and your knowledge, you know, and if it just is always taking, taking, taking.  Same as with anything in life; you run out of steam.  And I think a lot of the nurses are running out of steam.

Emergency nurses – their average stay in an emergency nurse as a profession is about two years.  After about two years, they tend to go to seek other things.  Sometimes the change comes out of necessity.  And I think more and more nurses have to find a way to have their voices heard.

I am part of the Emergency Nurses Association, and we stay up to date with national policy that involves

 the healthcare field.

I’ve been very active with Day on the Hill when we, as the emergency nurses, go to Washington DC, we tackle issues that are the most pressing at the time.  So we have that firsthand experience to tell them these are the stories that are affecting emergency care nurses throughout the nation.

My focus has been on the challenges we face with workplace violence, both in terms of understanding the magnitude of the problem, but also determining what we can do about it.  There is some legislation in DC around workplace violence and some mandates around what facilities need to do.  And that’s something that, yes, we’re going to continue to advocate for legislation on that.  And I think the more that we talk about it and the more that we gather data about it and really know the absolute magnitude of it, I think we will see that we accomplish greater things around eradicating workplace violence.

So we are really, pleased to be working with the Emergency Nurses Association, and we’ll have them come to speak with us now.  Last month –  our webinar last month was regarding the entire area of workplace violence.  And what transpired was that we understood and, as we go through the definition, we realize that the broadened definition of workplace violence encompasses much that is not physical much.  That is not just the physical typical violence that we would see and that we have been discussing.  And as a result of looking at this issue, we see that the nonphysical or verbal and non-verbal and threatening, intimidating, harassing, humiliating words or actions, bullying, sabotage, sexual harassment.  And so many of these are just absolutely critical issues that we need to address.

And they’re very hard to really discuss today because we don’t have the best definitions.  And so I highly recommend that you go back to last month and see where we are in the state of workplace violence.  And Vicki King from MD Anderson did a terrific job of reviewing that for us which was really spectacular.  And we really recommend that you go to our website and go back to see some of that work.  Now, what we’ve done is – what we’ll do today is forgo some of the preamble discussions for those of you that are with us live.  And we’ll be recording for those that are on our podcast.  But we have two terrific speakers with us today and reactors with us today.

And so, because we’re really blessed to have them, what we’re going to do is just move immediately to a discussion with Vicki.  Vicki put what you see on the screen – she has put together a terrific presentation for us.  And what we did was we asked Vicki and Chief Adcox to speak with us.  And we’ll first hear from Dr. Casey Clements.  So you’ll hear Vicki again.  We recommend that you watch her in our video in our last webinar.  But what we’ll do is we’ll move to Dr. Casey Clements.  Dr. Casey Clements is not only the clinical director of the emergency department at Mayo Clinic in Rochester, where I’ve had the privilege to do extra training and actually was on faculty in systems engineering, health systems engineering, but Dr. Clements has been an expert in sepsis for us for many years.  And he has now taken the lead on safety, occupational safety, and safety across the Mayo Clinic, and is very passionate about this topic.  So, what we’ll do first is listen to Casey Clements, Dr. Casey Clements, and then we’ll have Bill Adcox and John Nance, who’s a JD as well as a patient safety leader.  Bill is the Chief Security Officer and Vice President at MD Anderson.  And John Nance is a bestselling author and aviation and healthcare patient safety leader.  So we’ll hear first from Casey Clements.  Then we’ll go to the two reactors.  Dr. Clements, thank you for sharing your thoughts today.  Really, this is more of a conversation on nonphysical workplace violence.  Help us understand where we are in understanding it and how we can kind of tackle this.

Dr. Casey Clements:  Yeah, it’s actually a really hard question.  I’ve worked on workplace violence since 2014, and I still could not come close to defining the scope of the issues that we’re dealing with.  It’s, it’s a, it’s a, it’s a black box.  We don’t know what we don’t know.  You know, we do know that for physical violence, only 19% of events are ever reported and for nonphysical violence, it’s far lower.  We have done some survey studies on this and you know, their selection bias in those people are probably more likely to respond if they’ve had events.  But the nonphysical violence is far more pervasive than we’ve given it credit for.  And I’ve heard anecdotally from, for example, our, our phone staff at the clinic who, for people who are making appointments, that there’s just, there’s abuse happening all the time.  I know personally of stories where doctors have gone home from a shift, packed up their family, and left home for the night because of threats.  And certainly, we deal with harassment and everything from microaggressions to bias requests.  I don’t want a, you know, a person with a different color skin to take care of me, et cetera.  And all the way up to the significant physical threats.  So it’s, it’s a spectrum of, of problems.

Dr. Charles Denham:  So when we think about this, we’re going to be reviewing the ashram toolbox and the toolbox from the Emergency Nurses Association and others.  Everyone’s trying to get their arms around that.  Any advice for our frontline organizations that are wrestling with this area kind of feels like there aren’t clear handles on it yet.  And I’ll add one nuance to that.  It’s more than one incident.  Like when you look at the definition of each of these words, it’s more than one incident.  When you talk about bullying and harassment, intimidation, threatening behavior and that kind of thing, can you help us maybe put some handles on it, or kind of where we are, we’re looking at a number of frameworks?

Dr. Casey Clements:  Yeah, it’s a really good question.  You know, whenever you build a toolkit, you have it.  So they’re generally a little bit higher level so that you can, you know, how to build a system, what to have at hand, how to respond to different situations.  What I think is missing, and I think staff really need, is a highly reliable system to mitigate things and respond when bad things happen.  And, I don’t claim that we are experts in this.  I don’t think anybody is actually.  There certainly are organized follow-up programs with staff when things have happened.  But we really need a highly reliable system on how to respond.  And that goes beyond just a toolkit that goes into almost a playbook for if X then Y.  And, I haven’t seen something at that level of detail yet.  And, so we’re trying to grow that ourselves, and I suspect other organizations are as well.

Dr. Charles Denham:  So, Casey, when we talk about definitions, are there good definitions that we can use that might help us?  The joint commission definitions are broad.  What’s your take on that?  And then we’re going to show you one classification and see what you think of it.

Dr. Casey Clements:  Yeah, we use the joint commission definition that’s been updated in the last couple of years, and it is intentionally very broad and open to some interpretation that makes sense to me.  Since behaviors don’t usually happen in isolation, a lot of times there is a progression where, for example, someone may start with microaggressions against their care team.  And if that’s allowed to continue, that can progress.  So bad behavior kind of begets more bad behavior.  So it makes sense to me to have it broad.  That said, I understand that it’s really hard to operationalize systems around very broad definitions because the behaviors do vary significantly in that definition.

Dr. Charles Denham:  Casey, this is the Nash classification set.  Can you kind of crosswalk that with how you interpret workplace violence?

Dr. Casey Clements:  Yeah, and we’ve used this actually for many years.  And, I can tell you that for healthcare, because remember, this applies to just beyond healthcare.  The vast majority, the vast majority of violence that we deal with is actually type two violence, where it’s a patient or a visitor who is committing some act on healthcare staff. But, there is, and, we need to acknowledge this, there is some type-three violence in healthcare as well, where there can be bullying, intimidation, or mistreatment of coworkers or people we have a work relationship with.  And those are often handled differently.  We generally rely on HR for our type three violence.  And we try to manage type two violence in collaboration with security and the practice.  And I feel pretty strongly that the practice needs to be involved in that because security understands certain techniques, but we still have to care for these people.  You can’t very easily just end a duty to care for someone.  And so because we do that, that hand-in-glove collaboration between practice and security resources is really key.  And based on our information, it, you know, it’s a bit of an estimate, but I would say over 95% of the violence in healthcare that we deal with is all type two.

Dr. Charles Denham:  Could that be because a lot is underreported because we hear a lot about budgets getting cut and staff kind of being intimidated regarding their jobs?  If you don’t do this, you’re gone.  Or if they don’t act in a certain way their own livelihood is threatened.  And there’s really no place to report that.  So they just suck it up and deal with it.

Dr. Casey Clements:  Yeah, I haven’t actually heard of or dealt with that myself. Some of that probably comes down to the culture that we work in, right.  And I think that the cultures and the values of Mayo Clinic have not had that problem significantly.  There’s actually a lot of leadership support for doing the hard things and actually having these hard conversations about what we’re dealing with.  I haven’t seen that kind of intimidation.  So what forms of lateral violence do you think are out there to be aware of?  They, you know, talk about hidden violence, and they are really kind of referring to this lateral violence, and it’s one that we don’t talk about very much.

Yeah, I think that we do within education a lot of the time because there is an inherent power differential between a teacher and a student, or between an attending and a resident, for example.  And I think that there’s awareness that with that power differential.  There needs to be extra sensitivities toward behavior.  What I think we don’t talk about as much is the really true lateral, type three violence, which is sort of coworker on a coworker.  And those are, I think, vastly underreported when they are reported.  Oftentimes, you know, it’s handled internally to a unit, and so you may never hear about it at a higher level.  So it makes data very limited on what we deal with.  And there are special rules, you know, around employment law.  And when things go up to HR, we don’t get to hear about them.  And so, like I said, the response for type-three violence is necessarily somewhat different than it is for type-two.

Dr. Charles Denham:  So, Casey as we think about responding to the Joint Commission, is it reasonable to say that we have to cover all four types, even though some are more common than others, but at least have a mechanism?  And then the second thing is you mentioned the hand and glove relationships.  It’s really the practice, it’s security, it’s HR and anybody else that should kind of be part of that cross-functional team.

Dr. Casey Clements:  Oh, yeah, it’s really everybody, which sounds like not really a fair answer for you, I’m sorry.  But there, you need representatives throughout and, you know, we do a lot of triad leadership at Mayo Clinic.  So there are usually administrative partners, nursing partners, physician partners within the practice.  They definitely need to be involved.  But, we need frontline voices in on this.  And, you know, we don’t often include PCAs in our boardroom meetings, but we need to.  And so I think that all of those voices matter when we start discussing how we address the different types of violence.  I would also point out that with type one and type four violence being that those don’t have any business relationship related to the healthcare entity, those really are the responsibility of security.  And even law enforcement at that point, right?

So type one violence is a crime.  And how do, how is it that local law enforcement and or security to healthcare organizations are protecting people, places, and things?  And then type four, with the personal relationship, there are high profile stories of when that goes very wrong and someone comes in and assaults their ex-boyfriend or girlfriend or someone you know.  I think of the doc, the emergency medicine doctor in Chicago who was shot in the parking lot at her workplace by someone she had a personal relationship with.  And so that’s really the responsibility of security.  It’s really type two and three that get into internal workings more so and are very complicated to manage in healthcare.

Dr. Charles Denham:  So, as we have had our patients and families weigh in on this, they say, Dr. Denham, what about what Dr. McCay and others have said about the financial violence?  They say, well, you know, if the leading cause of bankruptcy in America are medical debt, and some organizations, and I’m proud to say having been on faculty at Mayo and worked with Mayo for I guess more than 15 years on many, many projects, I’m sure that this probably doesn’t occur with Mayo.  But Dr. McElroy describes hospitals going after families and taking away their homes and, and, you know, one city he referred to at 25,000 residents in 22,000 lawsuits by the hospital you know, financially going after patients.  And we’re hearing from our patient advocacy group, what about does that fit in this or not?

Dr. Casey Clements:  Again, you’re throwing me some curve balls this month.  I know it’s a hard area.  

Yeah. But that’s not something that I’ve heard of or considered before, to be honest.  And it doesn’t fit into the NIOSH framework.  But remember, NIOSH is for occupational stuff, right?  And so businesses going after individuals would not fit into a, a standard workplace violence schema that would be something separate.

Dr. Charles Denham:  So coming back to the leader, that targeting of leaders in our emerging threats community of practice – we know this is keeping leaders up at night.  And, we know, we recently saw in the press University of Arizona, who’s led by a physician, actually had faculty that kind of walked.  And this dissolved group that was working with the university regarding the death of a faculty member by a student.  And this is increasingly be becoming kind of a risk factor.  I know our team, our Med Tac team, we actually are training protective details of service and FBI officers to help with leaders addresses.  It’s not common, but it is something keeping everybody up at night and kind of on the worry list.  Do you want to address that?

Dr. Casey Clements:  Yeah, it’s a great question.  And, and I think it gets to the fact that neither the Joint Commission definition nor the NIOSH framework have anything to do with severity, right?  So the severity of a threat is very different.  If it’s from a demented person on a hospital floor who is mad at the nurse about having to take a medicine, and they say that they’re going to, you know, do something bad to that nurse, that is one level of, threat, especially if they don’t have the capability to, perform whatever thing that they’re threatening is at the other end of that spectrum is, I’m going to come in and I’m going to shoot my way through to the C-suite and kill everyone in the process.  And so there necessarily has to be some level of threat assessment.  This is actually something that I think we’ve gotten a lot better at over the last several years.

There are professional threat assessors for people that don’t know that through law enforcement as well as security to be able to, to come in and say, how is this likely to happen or not?  And they can take into account a vast array of resources to be able to get information both about that individual, about their history, about the criminal pos or about the possibility that they’re going to undertake some criminal act, et cetera.  And so we need to be careful when we look at these that the severity of any action, physical violence, nonphysical violence, has nothing to do with the joint commission definition or the NIOSH classification of types of violence.  The severity could be very bad in any of those categories.

Dr. Charles Denham:  So, you mentioned anecdotally about knowing of an emergency medicine doctor that moved him and his family out of their home because there was a potential risk.  We here in California, unfortunately, right in front of where my former home was, had an emergency medicine doctor run over – it looked really intentional, and then the driver on the video got out of the car and actually went after him with a machete, and he passed away.  And he was a much-loved emergency medicine doctor.  Now, the interesting thing is, the ED doctors we know that are on listservs – they lit up with a great concern.  And it sounds like many emergency medicine doctors are very concerned about their families and themselves, as evidenced by how many were inquiring if this guy was a patient or was this just, did this just happen?  So it sounds like there’s a, that there’s some significant worry about that in the emergency medicine doctor community.

Dr. Casey Clements:  Yeah. and I’m going to be careful here because I am an ER doc, and I represent that and I deal with these things, but I think we have to be really careful here, to not single out the emergency department.  The majority of violence in the hospital doesn’t happen in the emergency department.  It actually happens a lot of the times on hospital floors.  And we need to acknowledge that now, groups like the ENA have been out ahead of this for a long time, and there have been, they’ve had a decent voice that people understand that this is a problem in EDs, it’s also a problem elsewhere in the hospital.  And so I wouldn’t single out emergency medicine in this.  I actually think that this is something that concerns almost every specialty.  We know a lot about the ED, we know a little about the inpatient side.  We know almost nothing about the outpatient side.  And the outpatient side, ambulatory care violence is the next black box that we haven’t talked about and that we need to open up.  Because you know, if there is a discrete one hour appointment with somebody and they’re awful, or you’re threatened, et cetera, you’re less likely to report that because you can walk out of that room after an hour and think you don’t have to deal with that either again or until next time.  And so the report, I agree.

Dr. Charles Denham:  And I agree with you regarding singling out ED actually can, as a former cancer doctor, I can tell you it’s a big deal with dissatisfied patients and families and you know, in cancer, probably much more than the emergency department.  And we have had killings that have occurred even in Texas where I trained at MD Anderson, where disgruntled patients have done that.  Last question.  I know that you have only so much time.  Can you tell us about the legislative initiatives and your, it sounds like you are helping promote some new laws that could help us here.

Dr. Casey Clements:  So, there’s been a lot of movement in legislation in the various states over the last couple of years.  I know Arizona actually has some new laws that are pretty prescriptive about what needs to be done related to signage and notification of patients, et cetera.  Wisconsin actually passed a law last year which you know, maintains increased penalties for everyone within healthcare to help protect them from workplace violence.  In Minnesota right now, we’re actually advocating for some funding to really help healthcare entities.  And I say entities because part of this is hospitals, but you know, we don’t think about nursing homes and ambulance services in many other places in healthcare where this is affecting us.  But we’re advocating for some funding for competitive grants to be able to increase de-escalation or other kinds of training, improve infrastructure related to violence and move us from just response to mitigation and prevention.  And so we’ve been, we have a whole coalition of healthcare organizations in Minnesota that are working on that, and we’re helping out with that too.

Dr. Charles Denham:  Well, thank you.  Thank you Dr. Clements, I know this is an area of passion for you and thank you for the great work that you’re doing.  We really appreciate your insights.

Dr. Casey Clements:  No problem.  Thank you very much for asking.

Dr. Charles Denham:  So, Dr. Clements is the chief of the service, the clinical service of emergency medicine, but also safety, and we’ll look forward to having him back to set up Chief Adcox and John Nance to react.  We just wanted to remind you where this work has come from, and then Bill Adcox can kind of build on it.  In 2018, we started to focus on what was keeping leaders up at night or what should be keeping leaders up at night, the emerging threats.  And what happened was that we focused on now 30 different topical areas and focus on both inside threats and outside threats and vulnerability.  So you can go to www.globalpatientsafetyforum.org/, and you’ll be able to watch that video, and we’ll put that link on our site and you can watch the video of participation in that community of practice.

Basically, what we’ve said is our goal is to reduce the inside threats and the outside threats in a way that would allow us to have a greater safety zone, knowing we can’t reduce them completely.  This slide addresses those in just a headline sort of format.  And when we started, and we were focusing on it, workplace violence stood out as one of these top 30 areas.  However there was much overlap on some of the areas that are not physical violence.  And then when the Joint Commission expanded the description of what would be the definition of workplace violence, it, it, it actually causes us to look at a number of these areas, physical workplace violence, but also violent acts against leadership, which you just heard about just a moment ago.  Insider threats, intentional harm to patients, financial harm to patients.

I brought up there defamation and unfair press.  When you go back to the definition, it is actually cyberbullying that’s outside of the physical property of the hospital is included because it’s written or verbal, and it’s not limited to the physical property or real estate and then preventable death or injury.  These all now are kind of an overlap area.  And so, before we ask these gentlemen to react, we’re going to show just a short clip from the Emergency Preparedness Director, a frequent speaker on our behalf, Randy Styner.  He is the Director of Emergency Preparedness.  And I do this because we’ve expanded this community of practice beyond healthcare and academic and non-academic medical centers and hospitals to higher education. We’re actually participating in dialogue right now with a number of higher education organizations that do have medical centers, but we’re reaching much beyond that to higher education – our colleges and great institutions across the country.  So we have just a three minute clip of Randy Styner, who was in a meeting with us yesterday.  Randy, what do we need to know about leadership and workplace violence against leaders?

Randy Styner:  That’s a great question.  I think the first thing that you have to acknowledge in any type of, you know, situation or potential threat situations is the possibility of his existence.  Understanding that people in leadership positions could potentially be targets, you know, based on nothing other than the whim of somebody who wants to make a splash or, you know, in a violent situation.  So, understanding that is there, understanding that you need as a leader or in a leadership position to, as we used to say in our pilot world, is put your head on a swivel.  Make sure that you’re aware of what’s going on in your surroundings and take every threat seriously.  If something comes up, something that we may have been able to say beforehand, ah, that’s just somebody talking, you know, it’s more important.  And as a leader, there’s a much bigger risk, I think, to those types of statements.  Those are directed specifically towards leaders.

Dr. Charles Denham:  How important is leakage?  Meaning that when we’re hearing we’ve got some warning signs of somebody starting to make threats, social media and monitoring and getting ahead of some of these events.

Randy Styner:  I think it’s incredibly important.  I think in a lot of these situations of violent acts – I  mean, in my case, it’s in higher ed, you know, there was some, something foretold the potential of coming maybe not overtly saying, I’m going to be shooting up a place or something like that.  But there’s always those warning signs.  You know, any situation where there’s that potential for violence that has to be taken seriously by the university, by the administration by the counseling teams, by the police departments, you know, if those threats are out there, they cannot be looked at as being benign because too many situations have happened where these comments were made, they were being tracked, but nothing was followed up on.  And these people ended up, you know, taking a weapon and shooting up a school or a place of business.

Dr. Charles Denham:  Have you seen workplace violence going up in higher ed?

Randy Styner:  Oh, yeah, it’s definitely a bigger media story when it happens at school.  But in general, I mean, you look at what just happened in Michigan State University, you know, and other universities all through the country have been having the same issue, not just with people actually taking those steps towards workplace violence, but also in, you know, suicides are going up or drug addiction or overdoses based on, you know, the stress of the university setting.  I definitely believe that those, instances of violence on college campuses due to their ease of access due to a lot of them are public spaces.  You know, very few restrictions on coming and going, easy to do surveillance and blend in that all those things make higher ed institutions a good target.  Not to mention there’s a lot of people who have an issue, you know, they were kicked out of a program or, you know, didn’t get the grade that they wanted or something.  There seems like there’s a lot more stress factors that can sort of drive somebody down that road of, of eventually committing violence.

Dr. Charles Denham:  So, Randy and I have been in discussions regarding the broader context of academic universities with medical centers.  The story in recent historian Campus Safety magazine talked about this concept of leakage, which Bill, we would love to have you address.  And so what we’ll do is we’re going to have Bill Adcox and John Nance both react to what they’ve heard up to this point.  Now it would appear that we focused a lot on the leader piece.  And then what we’ll do is have Vicki King take a step by step through a framework that is much broader than just this area.  So we just wanted to make sure not to leave that area out.

Bill Adcox is the Chief Security Officer and vice president at MD Anderson Cancer Center.  He’s Chief of Police at the University of Texas at Houston.  He’s really a pathfinder in this threat, safety, science, and this area of threat safety.  And we’ll have a book coming out with him as a co-author, focusing on threat safety science in the future.  And then John Nance, JD, as he shared with me, he is going to be a triple captain.  He’s getting his captain’s license for oceangoing vessels.  But he was in the military, a military pilot JD.  He’s been a go-to patient safety leader for us in hospitals in patient safety, formerly on the board of the National Patient Safety Foundation, a Good Morning America commentator, and also a bestselling author, both in fiction and non-fiction books.

And we’re looking forward to hearing from him.  And so Bill, what we’re going to do is go to you and then have you react to what you heard from Casey, then go to John, and then Bill, we will then play the recording we did with Vicki this week with you, and have you cover the four Ps, which we’ve already got in that clip or in that video tape.  So Bill, go to you first and then to you John.

Chief Bill Adcox:  Well, thank you, Dr. Denham.  It’s great to be on the program.  A lot of information was covered and many areas to cover, but I want to make a couple of points.  Number one is the broad definition is important.  Joint Commission’s, broad definition.  And, remember, not all workplace violence is a crime.  And so, therefore, that multidisciplinary cross-functional team is very critical.  And so here in our environment, we’ve added our own fifth typology, and that’s suicidal ideation.  And we do that because, you know, you were just talking about it with Randy about, you know, all the students and the different individuals that are attempting to take their lives.  And many of them complete that.  And it’s very much of a problem.  And here, working in a cancer environment, you can only imagine the despair that goes on.

So that’s important to know that you can expand on that a little bit.  That’s why these broad definitions are important.  So Dr. Casey Clements mentioned there’s no severity issue that’s there.  So what I would say to people is that every organization is different, and some of these organizations are large and have a lot of resources and a lot of expertise. Some do not.  And so, I believe what you do is you look at a general framework, and then you really go into your own organization and look through there. You really need to look at what you need to do to actually have a threat assessment capability.  So, I would say to you, for example, let’s say you have a smaller hospital system, maybe a regional hospital that does not have a lot of resources where you might not be able to hire an employee, a person that has threat assessment expertise.

But you certainly can have a partnership and an agreement with your local authorities, your local law board authority, offer them a grant, for example.  So that, that grant is to send someone to the Association of Threat Assessment Professionals in California for a week to help get them acclimated and become a member to learn about it, become more of a proponent towards threat assessment.  And then you have some go-to people within your own local authority that understands what you’re going through.  You can do these types of things  based on the size of your organization.  So the other thing is to understand that there’s both targeted and effective violence.  And one of the things that they’re talking about is leakage – you talked about leakage earlier.  You don’t have leakage when it comes to effective violence.

That means someone just blows up and attacks or does something.  There’s no, there’s no pre-work up to it, but there’s almost always leakage when there’s targeted violence when people are upset.  And therefore, you have to have this system in place.  So really, you need to have integrated systems, integrated information coming in.  So that’s why it’s so important that you have HR, that you have your security department, that you have the clinicians involved.  The practice is critical to take the lead so that you’re getting this information and you’re able to put it together with a multidisciplinary team.  Then you have the threat assessment part where they can actually look at the severity.  They can actually use structured judgment tools and in order to grade it and find out what the risk is and bring it before the multidisciplinary team to set up safety plans, set up management plans to take a look at the needs to be done to get somebody some help.

So you can bring that threat level down.  Then you also need to have that behavioral intervention team, which is that multidisciplinary team that’s looking at this threat assessment that’s coming in, that’s looking at what needs to be done.  And ultimately, where Dr. Clements said that as far as the mitigation and the response, that he believes that there’s a weakness there and that no one’s really got a, a great handle on it where they need to be.  That’s where you really need to look at having an interventional team availability, a team or whatever, somebody that can respond to the floor right away with the right expertise, knowing how to take care of things with the right type of restraint, methodologies or whatever, whether it’s Samma which is better than, say, what law enforcement uses as compliance, that’s not really a good thing in a hospital setting.

So you need to have that type of deal.  But again, you need to have a framework, a general framework.  People need to come together and say, okay, what can our organization do?  And put something in place.  Something is better than nothing, and don’t think that everything’s going to, there’s not going to be perfection.  You’re dealing with human behavior, human emotions, and it’s going to be very difficult.  But the key is, is that everybody needs to be on the same page.  You need to have executive leadership support and just get something done.

Dr. Charles Denham:  Fantastic Bill, we really appreciate it, and you go into a little bit more detail in the in our program on effective and targeted violence.  And after we finish that program, I’ll ask John to respond regarding the role of boards, but we’ll do that after we hear Vicki go through the framework. So, John, your reactions up to this point in time and then we’re so blessed to have you then react after Vicki goes through a step-by-step approach from the toolbox.

John Nance:  Well, it’s, it’s very good to be here.  And I think this is not only an emerging knowledge base, it’s also something that really the population needs to be aware of.  We’ve got a meaner population than we did before.  We’ve got a lot of pressures of various sorts.  Certainly, three years of covid hasn’t helped anything.  And looking just broadly across all professions, you see an incivility that has been increasing with the lack of educational quality for probably the last 70 years.  So we have, we’ve put ourselves as a people into a different arena here that we’ve got to deal with on something other than just the reactive basis.  As a matter of fact, one of the mainstay is you’d well know in aviation which has been, you know, one of my premature areas has been to try to get ahead of things by expecting failure, mostly human failure.

That’s what changed us in the eighties from a reactive profession in which basically would give people complex airplanes and say, you boys, be careful out there now, here, here.  Rather than saying, okay, here are the things that can go wrong. Here are the ways that people fail.  We’re going to build a matrix of capability to absorb the failures that we can no longer stop.  And, and I think that that really is where we are today.  You talk about violence in the workplace, or flight attendants, for instance, right now, this is worldwide, but especially in the United States, we’ve got a lot of angry people.  Some are unbalanced, some are just angry, and some are drunk.  But the fact is that we’ve never had a situation like we have in the past, probably 10 years in which the level of assaults, physical assaults, on some flight attendants and crew members in general have just been getting completely out of hand.

Used to, the federal air marshals didn’t have all that much to do except for the occasional worry about a hijacking. Nowadays, they’re suppressing violence, in the cabins at all times in all places.  Anyway, that’s just to say that I think the process of making people aware of how, and I hate to use this term, but ubiquitous, this is becoming in terms of mean reactions, surly reactions, unhinged reactions, and most of them are reactions.  And sometimes just an aggressive inability to handle your own emotions exploding a, in a situation where it might be otherwise understandable.  In other words, a loved one is having trouble getting into the ED.  Somebody just finally gets to the explosive stage.  All of this needs to be handled, not in a way, a kind of an esoteric, this is what can happen, but, and this is what is happening, and we’ve got to be able to take care of it, especially with respect to knowing the signs and the symbols and the precursors.

I would tell you there right now, that I think there’s another form of violence too.  There are a lot of categories in this.  Now, one of the forms of violence that bothers me an awful lot because I’ve seen a lot of it over the last 25 years, increasing is nurse-to-nurse hostility in the hospital workplace.  And the fact that it is so indigenized that it isn’t even recognized to a certain extent.  I have very veteran nurses look at me kind of in puzzled fashion when I say, you know the statistics of nurses, new nurses leaving during the first six months because no one was socking them in the nose, but they weren’t supported.  A lack of support, a lack of a base of camaraderie.  Lack of teamwork is a form of assault in terms of a situation where you’re expecting high levels of functioning from people and you’re not getting it.

So there, there are a lot of things that we need to take a look at, just very much the same as the FAA and the Department of Transportation this week are having a get-together in McLean, Virginia to lay out on the table all the things that they know about.  Some of the recent incidents in aviation is for the purpose of saying, let’s get down to the anatomy of this and look at what we’ve been looking at, but maybe haven’t been seen overall, where are these elements?  And, they don’t have to be physical, as I say, they can be just a lack of support.  But I think the more we understand about this, I mean, it’s all human.  Of course, the more we understand about it, the more we’re able to react in a way that isn’t just purely reactive, but it’s actually proactive in coming up with different basic, solutions.  I would also say threat assessment is probably the right term, but we’ve got several different terms floating around. Prediction is part of it, but the ability to simply say, okay, this is a ripe environment for trouble, and do we have a methodology of expecting it?  Anticipating it, and whatever we come up with in terms of, of the way to react to it, have we educated all our people, not just given them a road show, but I mean, really indigenize this into the culture.

Dr. Charles Denham:  John, thank you so much. I want to make sure we have enough time for the whole program of Vicki, but you’ve brought up some really critical points, and I want to go back to both of you on this, and we’ll keep it fairly brief, and then we’ll have a longer time, John, for you at the end.  But you brought up some really key issues, and you brought up the issue of the flight attendants.  And I remember back when you and I were on the board of the National Patients Aging Foundation, and we were looking at the NASA reporting system by pilots when they would be reporting near misses and issues like that.  I just want to ask you how is reporting going of workplace violence with the flight attendants and the airlines.  Just see what our state is.  And then Bill, come back to you.  I know you’ve got some wonderful thoughts about reporting and why reporting is so important and what you can do as a leader for culture.  So I just wanna cut back to both of you real quick, and then we’ll go to Vicki.  Okay, go ahead, John.

John Nance:   Well, I’m glad you brought that up.  There is a lot of dynamic tension between and among the airlines, in particular, their employees, and the unions involved, and there’s a lot of finger-pointing.  And basically, on the basis of people not being able to speak up because they end up basically having something done directly or indirectly to them that impugns their ability to  feel like they’re safe.  In other words in most cases, there’s no formal response that’s negative.  There’s nobody saying you shouldn’t have spoken up.  But in some airlines, and I could tell you which ones you can end up losing your job as a pilot or a flight attendant by talking to the media about anything at any time.  And this simply isn’t right.  This is a form of intimidation that runs to the heart of them reporting anything.

There’s a case that has bubbled into the public arena just in the past few months of a senior captain at Delta Airlines.  Now, I won’t get in the names, but she’s been she’s a Ph.D., very accomplished lady.  And she came to her airline, flew down to Atlanta a number of years ago, and with plenty of credentials, basically laid out what they needed to do to improve their safety system.  The response was to try to certify her as crazy.  Delta has had to pay a lot of money for this, and the embarrassment is there, but they have not learned a lesson, I don’t believe, I don’t think any of the airlines have t.  It is so easy to retaliate directly or indirectly, and all you do is do that to one person, and you have chilled everybody else.

Dr. Charles Denham:  Bill your thoughts on reporting, and then we’ll go to you and Vicki.

Chief Bill Adcox:  A couple of things.  Thank you very much.  John, talking about reporting.  If we do not know what’s really going on, it’s impossible for us to develop a response to, to it.  So I will tell you for sure that threat assessment professionals are, never in the prediction business.  They look at severity, they look at risk, they look at probabilities.  So it’s very important that you have the professionals.  But the other piece of it is, is that when you really, when you think about this, this issue of retaliation and John, you said it, you know, one person gets retaliated against and it just sends a shock mm-hmm. <Affirmative>. So to me, there’s an old saying that says that, you know one person’s perception is their reality.  And so, if people perceive that there’s a tremendous amount of retaliation going on, then, that’s the way they’re going to react.

And so the facts, small moves come into play.  So we have to be real careful that we have a culture of trust, a culture of safety, in all of our organizations.  And I think that’s important in our business in terms of knowing what, where the crime is.  They’ve done studies, they do victimization surveys, they do arrest surveys, and then they take a look at other types of data and information that’s coming in to be able to pinpoint if the community does not trust their law enforcement.  The community does not under trusts their district attorneys in order to prosecute that.  There’s no trust.  A lot of crime’s not going to get reported.  There’s only two crimes that’s going to get reported.  One of them is homicide, and the other one’s auto theft.

Cause you need a vehicle.  Mm-Hmm. <Affirmative>. Other than that, people are don’t always going to report things.  So you really don’t know what’s going on.  How are you going to, how are you going to have an effective response?  Same thing as workplace violence.  Same thing as with retaliation.  Same thing.  We have to have open, honest, and trustworthy organizations at the very top leadership that support people to have, have a level of principle bringing in character-based people to the organizations.  And let’s, and, and, and we can root out some of these problems.  But, that’s what I was saying, and I thank you very much for the time, Chuck.

Dr. Charles Denham:  Thank you so, so much.  I’m going to jump right in Bill so that I know that you have a hard stop and I want to come back to and give generous time to John.  We’re so blessed to have you with us today, John, but also to address the board issues.  So thank you, Bill.  And what I wanted to do, just to introduce Bill and Vicki King, covering in very good detail just a few documents that all of you should be aware of.  First off, the ECRI top 10 claims, as you can see here the number two claim is physical and verbal violence against healthcare.  This is for 2023.  They have a report you can download if you tell them who you are, and I highly recommend that you review all of them.

There are a number of topics that are close to our hearts.  We’re also doing a lot regarding children and drowning and preventable harm, but we won’t cover that today.  Want to show the second slide of the two-slide series that we have just drawing your attention?  They rank at number two, and you’ll see that nurses are at 26%.  But, it’s very interesting that we’ve got a pretty high number for our physicians.  And then the ashram Workplace Violence Toolkit we didn’t today have enough time to really go through it.  We think it’s excellent.  And, we think that all of these frameworks need to be adjusted to your organization because it’s absolutely critical to customize them.  The toolkit for mitigating workplace violence is excellent.  And what we’re going to do is use these topics as a way of having the discussion now with Vicki King.  And we’ve taken each one of these with Vicki and then John we will  be coming back to you.  So what we’d like to do is have you watch Vicki, we, she is speaking at a national conference on workplace violence today.  And so we recorded this on Monday.

So, Vicki, thank you so much for your prior presentation in our kind of part one of workplace violence.  When we talk about the nonphysical categories or discussion regarding the nonphysical violence we really need to have some good operational definitions.  You know, when we talk about threat and we go through kind of the list of the various terms that are used in the joint commission definition, how do you tackle that when you try to put together plans and policies and procedures?

Asst. Chief Vicki King:  Well, when you begin to look at the specific types of behaviors and everything needs to be behavior focused.  And when we start to think about what is a threat, well, you may think, a threat is a distinct communication of intent to harm.  And that’s how most of us think of it.  But there are so many other things that really constitute a threat, especially in the nonphysical world.  You can have an implied threat.  You can have a conditional threat.  It’s not just the overt threats that are out there.  You can have actions or behaviors that become threatening to someone’s job, and their security in the workplace.  So it’s a very broad term when you say threat and drilling down and thinking about what does that mean within your institution because that really frames what your response is going to be.

Dr. Charles Denham:  So, most organizations, and we’ve discussed with Casey Clements that they’ve been left pretty high levels, so it’s kind of hard for somebody down lower in the food chain to be able to say, well, is it a threat?  Is it not a threat?  So does that leave it to organizations to really come up with a good structure?

Asst. Chief Vicki King:  Oh, absolutely.  Coming up and, and deciding how you’re going to handle and what, if you’re going to create a culture of safety within your organization, you have to think about what it means not to be safe or to make someone else not feel safe in that work environment.  And so being able to define some of these terms so that people are put on notice, first of all, that that type of behavior is not acceptable.  But then also to be able to take concrete actions to mitigate and stop those actions in their track is very, very important.  And we always fall back to policy.  What does our policy say that is prohibited conduct in the workplace.  And then you can begin the conversation.  And many times just having a conversation about someone’s behavior can alter that trajectory, because what you ultimately want to do is decrease the severity and frequency of those events.

Dr. Charles Denham:  And, you know, when we worked on the NQF state practices, we talked about frequency, severity, and impact, clinical, operational, and financial.  Before we talk about mitigation, and that’s where our four kinds of – the four P model that we use is there as we go through each of the words that are in the definition.  When I read harassing, when we look at the Webster dictionary: to annoy persistently to create an unpleasant or hostile situation, especially by uninvited and unwelcome verbal or physical conduct, now we’re talking about more than one incident, and it’s over time there’s a temporal component.  So not only do you have to understand harassing, but these may be patterns and not just an incident.  Can you help us with that?

Asst. Chief Vicki King:  Sure.  And the patterns of behavior and, we also have to have context and perceptions are also going to be players in that evaluation.  But when you start to have a pattern of behavior where the incivility or the threatening behavior is observed over multiple incidents and many times with multiple people, then we can bring that back to the employee and say, look, this isn’t just a one off.  This is something that requires intervention.  And we want to figure out what is the best strategy to either bring the employee back on track or to take more concrete disciplinary practice up to and including removal from service.

Dr. Charles Denham:  Well, you know, and then that brings us to one that’s really hard to put handles on, and that’s the term humiliating.  And the, legal dictionary is an act extremely destructive to one’s self-respect or dignity.  Humiliation is something I feel, but it’s very hard to kind of put it, you know, call that a scalpel or a gun or something, isn’t it?

Asst. Chief Vicki King:  Absolutely. And that’s where perceptions come into play too, because sometimes you have to manage the expectations of the person.  There, there could be a patient who felt like a medical procedure was humiliating because they had to disrobe, or they had to be in front of someone of the opposite sex.  And certainly one of the things that we, we know in the clinical setting that if the care provider explains to them in advance what the procedure’s going to be, this is what we’re going to do, this is the why behind it.  It, can tamp down those expectations and create a more comfortable environment.  You can take that same process and apply it into a workplace situation, for instance, in an emergency department many times time is of the essence.  You have to speak quickly, sometimes pointedly sometimes correct on the, on the moment, on and, and correct trajectory if somebody is getting offline and they feel that that was a humiliating experience.

Again, context, bringing it in, and sometimes just, talking to the individual who felt humiliated and having a conversation with the person that they felt like was showing them a level of disrespect can go a long way into mitigating future occurrences.  And you come to a meeting of the mind, one of the things that is one of the worst things that we can do is ignore it completely.  Someone comes to you and tells you that they had this experience, and you say, oh, that’s just Dr. X, or that’s just how that person is.  That person needs to know how they’re being perceived by other employees, and the employee needs to know, understand the context and why that occurred.  You wouldn’t be pointed with somebody in just a an average clinical setting.  You know, when everything’s calm and you’re just evaluating a patient.

But certainly in an emergency department, especially if it’s a trauma event, you don’t have the time or the luxury to stop and explain.  And sometimes we can educate both sides about how we can be a little more gentle a little, and, and be a little more open and receptive to those events that kind of stick in your cross.  And sometimes just talking it out or having someone say, I understand how you might have felt, but this, this is what the context was.  Those things can go a long, a long way in repairing relationships and building strength between your colleagues that may have been a bit fractured by a specific event.

Dr. Charles Denham:  Well, we’ll talk in a few minutes about the categories of violence.  We’re talking about the definitions, but humiliation is one that really comes into play when we talk about lateral violence within caregiver to caregiver, and also when there’s a power gradient.  Isn’t that right when there’s a superior and an inferior that might be educational, but it may be just operational, that power gradient can tend to be abused?  Is that correct?

Asst. Chief Vicki King:  Absolutely. And one of the things we who may be in a position of power need to understand the strength of the language that we use, the terminology that we use, and to have a bit of sensitivity.  Because if my boss corrects me, especially in a public setting, I’m going to feel humiliated.  And, and may feel that I’ve been denigrated and dressed down.  You know, you certainly want to be sensitive, especially if there’s that power differential.  Whereas a colleague, if a colleague said, Hey, you did X, Y, or Z, I might take that a little bit easier because I’m not being shown it.  It’s a, it can be perceived more as a helpful comment than criticism or something that’s going to harm my reputation with others.

Dr. Charles Denham:  The next term in definition by the Joint Commission is bullying.  And if we look at a legal dictionary, abuse, and mistreatment of someone vulnerable by someone stronger, more powerful, et cetera, the actions and behavior of a bully, and that’s where the power gradient really comes into play.  And there can be bullying that can be initiated, but also retaliatory bullying after a caregiver may report a safety event or other issues.  What are your thoughts about bullying and the specifics of that power gradient worker to a worker?

Asst. Chief Vicki King:  Well, bullying is probably one of the most destructive forms to cohesive group dynamics, as well as it can erode patient care.  If you feel that you’re being bullied by someone, the natural human reaction is to avoid that person.  You, you don’t want to engage them.  You want to limit your contact.  It’s a protective measure.  Well, when you do that in a clinical setting, and that is the provider, and you are there as, as the nurse who’s trying to carry out the doctor’s instructions, if you don’t understand something, you’re not going to feel comfortable in going and asking for clarification.  You’re also not going to feel comfortable if you feel that there is a stop-the-line moment where you should say something because you’re, you are fearful not only of the, the immediate visceral reaction of the, of the person that you’re trying to point something out too, but even more important, the retaliation, that could be a career-defining moment.  It could be it could really create problems for you with others if that person engages in sabotage, which is another aspect of the Joint Commission step definition.

Dr. Charles Denham:  And so, sabotage, you know, a major medical center, in fact, number one in the world, MD Anderson, number one in US news and world rankings, in almost every ranking you’ve got nation-state activities that might occur and not even know that you have an operative that might be trying to sabotage or steal something that’s there, and they might be sabotaging someone else or even the organization.

Asst. Chief Vicki King:  That’s right.  Professional sabotage really cuts not only to the heart of the organization or the individual but also to the heart of the organization.  Because when you steal someone’s intellectual property or try to discredit that person for personal gain all of those things do not advance science, and they create tensions and potential ramifications far beyond the initial event.  So those are something that we, in the security field, need to be sensitive to and, and help develop the protocols and protections for those staff, and also mechanisms for reporting it so that immediate mitigation efforts can begin.  There’s an interesting story about a Rabbi who said I, I just love this story because one of his congregants spoke ill of him and really damaged his reputation.  He confronted the congregant and the congregant said they were sorry, what can I do to make amends?

And the Rabbi said, well, you can go up to the highest mountain, take a feather pillow and release all the feathers into the air.  And the man said, okay, will that fix the problem?  He said, no, that what will fix the problem is step two, you go and collect all the feathers back, because once it’s out in the air, once it’s out there, correcting the negative becomes almost an impossibility.  And, and I’ve always thought about that, that story when it comes to sabotage, especially with someone’s career, sometimes even an allegation of an event can do irreparable harm.

Dr. Charles Denham:  Especially in this.  And Chief Adcox is listening and will be reacting, but in our green room discussion, we talk about this highly lucrative process of generating rage porn where we can get people angry about something.  And a false alleged allegation can play to the strength of their being mad and being maybe disrespected and ha take a life of its own.  So with sabotage, liable and def defamation are both legal terms, and they would be coupled to that, wouldn’t they?  If you’re working with professional to professional, especially in an academic center like yours.

Asst. Chief Vicki King:  Absolutely, and certainly, that can take place, but what is hard to have actionable are rumors.  You know you can sabotage someone’s career with an ill-placed rumor, and before you know it, it spreads like wildfire.  And getting back to the origin of that rumor is almost impossible.  And we see this with social media where people will have anonymous posts, oh, this doctor did this did X, Y, or Z. This person was bad because I heard that they did X, Y, or Z. And it begins with that anonymous posting, and then the rumor mill takes over and really does the work for you.

Dr. Charles Denham:  And this information disorder of misinformation, disinformation, and mal information, we’ve learned that it’s very lucrative to spread the attention-getting disinformation maybe six or seven times the stickiness in Facebook and Twitter and, and social media.  So then we, you know, we’ve talked about when we talk about assault, we immediately think about the physical, but our topic today is really the nonphysical, which is verbal.  How do you tackle the verbal abuse?

Asst. Chief Vicki King:  Well, we assess the level of verbal abuse, and, and we look at the context with which it’s offered.  We talk about the difference between effective violence and targeted violence.  So effective violence is that momentary flash.  Someone gets bad news about a diagnosis or bad news about the outcome of a procedure and that, or they’re struggling with pain, and a nurse comes to do a procedure that becomes painful and they lash out.  That’s that effective moment.  And when we evaluate those, we look at the context of it.  And if it’s emotion driven, high emotion, a, a quick flash, and the person in the, when things calm down is able to apologize, accept responsibility for those events, then we know that that’s someone that we can work with.  And then we work with the clinical team to manage the pain so that they know what or to manage a trigger.

So we’ve had some patients who lose their cool when they have to wait an, you know, longer than necessary in their mind, time for an appointment or appointments change and their scheduling changes.  We can manage those trigger points and deal with those issues.  What is really insidious are those threats that are tied to a specific grievance.  So in the medical profession, if you feel that a provider has caused harm through what they believe is some sort of malpractice or malfeasance, and even if it is, and this is where most people don’t understand they think, well, that’s been examined by the medical board, or they can make a complaint and they can do all these things.  There, they can redress their grievance.  But if the, if the grievance is completely in the mind or in the eye of the person who’s offended, the grievant logic and reason aren’t going to play into that.

They have emotions tied into that.  And those are the more difficult ones for us to mitigate.  There are a number of strategies that we employ there.  The first is just an easy contact to let them know someone’s listening.  Give them an opportunity to vent, give them alternatives to redress that grievance.  And, what we’re trying to do is show them that they have value, they have worth, and they’re being heard.  The outcome may still be the same, but giving them the time and patience to deal with that helps mitigate the event.  The really tough ones are when those goalposts keep moving when you meet this issue, then they jump to the next and jump to the next and jump to the next.  And you get some fatigue there with your mitigation strategies on trying to address these.  And at that time, you have to set guardrails up and they may still rail against them, but then when you demonstrate all the steps and all the things that you’ve done for them, that injustice warrior or that grievance collector, you begin to, to let a little bit of wind out of their argument, you begin to, to, because they’ve had some success, and you can, you can celebrate those successes with them.

They move on because now you have addressed their concerns.  Those are some of the most difficult ones for us to wrap our arms around.  And they’re the most frustrating for our clinicians who are truly trying to do the best they can to provide the best care they can in a timely, efficient manner.  And these people begin to suck all the oxygen out of the room.  They begin to inordinately occupy your time.  And so that’s where your patient advocacy groups, your social work, your threat assessors, they can step in, alleviate that for the provider, and then begin to manage that problem patient or that problem family member.  And that’s how you mitigate the grievance downstream.  So you really have two avenues.  You have the ones that are the flashpoints that you can reason with afterward, and then you have those who are the most difficult to work with, and those who feel that they have a grievance that’s not being addressed to their satisfaction.  And many times these folks have other issues psychological, and mental illness borderline personality disorders.  We’ve seen some of those.  And so you have to take them almost step by step.

Dr. Charles Denham:  You know the last term to discuss a definition is aggression.  And the legal dictionary calls it a forceful action or procedure such as an unprovoked attack, especially when intended to dominate or master.  And again, when we look at this, there could be that immediate flashpoint, but also some of this kind of aggression, especially in the lateral violence environments, is protracted over time, isn’t it?  Where you’ve got somebody who is intending to dominate or master, be they with a power gradient or no power gradient in the hospital or academic center Fair statement.

Asst. Chief Vicki King:  Absolutely. Calhoun and Weston have done some research on this, and they talk about the need to regain control.  And that being one of the motivating factors for aggression.  When people become aggressive, that fight or flight they want to regain control over a situation for which they feel they don’t have control.  And so understanding where they’re, they’re coming from and what their ultimate goal is, is part of your mitigation strategy.  So you’ve got to give them some measure of control somewhere.  But what you are trying to do is channel and funnel that anger or that need for control into a healthy outlet.  One of the things we talked about is when someone threatens litigation, that’s really a healthy outlet because it’s a legal process, it’s a civilized process.  It is a protective way for them to, and so you, you point them in that direction, that may sound counterintuitive.

Why are you pointing them to a legal process?  Because it gives them a measure of control, something that they are doing positively to address their grievance.  It may be complaining to internal structures to try and have an aggressive outlet that is positive.  If, if they feel that things are spinning out of control and they have no outlet for it, physical violence and aggression can occur.  And that’s what you want to, that, that is what we’re, we are working against, is to keep someone from running out of good, viable outlets and options for their anger, their aggression and, and have it morph into a, an actual physical event.

Dr. Charles Denham:  What a great description, man, that should be tattooed on everybody’s forehead.  I mean, that’s a great statement because you know and, and it’s counterintuitive as you say, you think, oh, well, they’re threatening to sue, and you’re saying, here’s a good structure or structure through which to vent this energy.  And that makes so much sense.  So, Vicki, we’ve discussed the fact that a lot of us really like the toolkit for mitigating violence in the workplace that was developed by ONL.  And can you just walk through each of these steps and just give us your take on where we can get started and why it’s important?

Asst. Chief Vicki King:  I’m happy to.  When we look at the workplace violence toolkit that’s provided for us here when you look at step one, it’s really to understand the universe of workplace violence.  And it means more than an act of physical aggression or physical violence.  It’s those nuanced pieces that give us an opportunity for prevention. And that’s really what we want to do, is prevent an escalation either in frequency or severity of an event that would culminate into an act of physical violence.  So understanding that sometimes the best intervention, just like in the medical world, is to catch things early and address them head-on.  And that prevents this from really morphing into something more insidious.  So when we go into step two creates the culture of nonviolence, that’s so much for our employees and for those who are seeking treatment and visitors, we’re going to set the, the stage, we’re going to set the guardrails up.

First of all, our staff doesn’t have to tolerate it.  It is not part of the job.  It is not something that should be acceptable in our places of healing.  And I’ve seen some great signs that have gone up in hospitals around the nation where they begin to put those who come to the hospital on notice that this is a place of healing.  It’s not a place it’s aqua a place of calm, reflective healing we’re of civility that we’re here to help.  And we can’t help if things get out of control.  So they, they, their messaging is, is, is one of, we are here to help, please help us attend to your needs by keeping things civil, by not raising your voice, by not being argumentative, by following the rules.  So setting that culture of nonviolence, not just for the employees, we always tell the employees this, these are our expectations for behavior in the workplace.

Let’s also convey those same expectations and have follow up mechanisms for when someone is unable to control themselves or violates our rules.  How do we deal with that person?  When we talk about zero tolerance, it’s a zero tolerance for bad behavior.  It doesn’t mean that every bad behavior is going to result in ejection from the hospital.  So you may have zero tolerance for behaviors, certain behaviors, but that doesn’t mean that there aren’t mitigating circumstances that would allow that person to stay there, but they’re just going to have to adhere to our environment of care.  They’re going to have to be able to follow our rules.  And when we talk about assess and mitigate risk factors, this is, this is so important from a standpoint of prevention.  So when you catch behaviors, when someone begin enters the hospital and they begin acts of incivility with your reception personnel, let’s address it right then.

Let’s not let them get a pass.  Let’s not let them think that that’s going to be okay.  Let them know what the rules of behavior are.  So then when they get back into the clinical setting, they don’t feel like, well, it was acceptable out there.  It’s going to be acceptable in here, and I’m going to take it up a step to get what I want.  And so what we, what we’re, that goes back to your culture of safety when you’re setting these expectations.  And so there are a number of really great tools that are out there when a behavior occurs to be able to evaluate, is this a low threat situation?  Is this a moderately threatening threat situation?  Is this a high-threat situation?  And we look at structured judgment tools.  Many hospitals use the process, which is a six question structured judgment tool.

It’s very easy.  And what it does is it tells you if the patient or family members exhibit these types of behaviors, you need to be on guard that there could be an escalation.  And then there are others that are out there, the waiver 21 stalking assessments.  We’ve had patients that have unhealthy attachments to their caregivers.  So it’s finding the right tools and gathering as much information as you can so that you can properly assess where this person is, what the context of the behavior was, and is there a potential for escalation.

Dr. Charles Denham:  And then step four, developing a workplace violence prevention program.  I think you guys are really leading the way there.

Asst. Chief Vicki King:  Well, we are, we stand on the shoulders of giants, I can tell you that.  We look at the research, we look at the work that’s been done on workplace violence prevention.  And what we want to do again, is get ahead of the program, identify behaviors while they’re relatively minor, and have intervention strategies to address them so that they are unnoticed.  And we can prevent that escalation in frequency and severity assess it, and then take those mitigation steps.  We talk a, a great deal around here.  Sometimes the Hawthorne effect is what you need.  You just shine a light on it.  You just pay attention to the person.  You let them know that they’re heard, but then you accept you, you set the boundaries, you set up those guardrails, let them know in advance what the consequences are for violating those rules.  And many times you can get compliance even with some of the difficult individuals or people with chaos in their backgrounds.  You can certainly be able to set those expectations in this environment, this healing environment.

Dr. Charles Denham:  That’s great.  And then from the standpoint of continuously training and deploying staff, I know you also are really leading the way there. Your thoughts,

Asst. Chief Vicki King:  Right.  And this is so important because there’s constant turnover in any healthcare facility. You may have contract nurses, you may have technicians.  You certainly have abundant shift change.  So being able to have those touch points through emails, safety moments at the beginning of every meeting, safety moment at the start of every day with your clinical team as part of the handoff.  What are some of the problems that we’ve seen with this patient or these family members over the previous shift and what was successful in mitigating some of their concerns?  So you can do de-escalation training.  CPI is out there.  It’s been extremely effective.  Having touchpoints with your security team in the units, talking about everything from active shooter.  We’ve had active shooter, not drills, but touchpoints where we go and we walk into a clinical space and say, okay, if there was an active shooter, what would you do first?  How would you protect yourself?  How would you protect your patients?  How would you deny, defend what, what strategies?  And then you have a conversation while we’re in the cool light of day, and they begin to look at their workspace differently.  That’s a training touchpoint.  We do 15 minute sessions in the workplace just talking about active shooter.  It also promotes conversations.  Now they have the business card of the person who they spoke with, and if they have a workplace violence issue of concern, they have someone that, another human being, Hey, I just wanted to run this by you.  And we begin the conversation.  Safety and workplace violence prevention should be in almost every conversation we have when we are talking about training and developing our folks.

Dr. Charles Denham:  Fantastic.  And then as the Joint Commission says, measurement and having this continuous, this systems.  So final point your thoughts about evaluation and measurement of the impact of your systems.

Asst. Chief Vicki King:  Well, it, it’s funny, you know, we started those 15 minute touchpoints almost a year ago now.  And the feedback that we have gotten from the clinical staff is amazing.  They feel better connected with our workplace violence prevention program members.  They feel appreciated.  They feel that the institution is taking it seriously.  And one of the most important things is when someone calls and reports an incident, we follow up with that person most of the time, within 24 hours, unless they’ve gone off shift and we can’t reach them, they’re sleeping. There are a few minor exceptions, but the main thing is when they report it, that they feel like they get immediate feedback.  We’re here, we’re listening.  And when you do those things, when you, when people feel that they’re being heard and listened to, and then they see the actions and the explanations of why we’re doing things, the confidence level begins, and then they begin to share that with their colleagues.  Again, let’s make that rumor mill that was so destructive in the sabotage area, work for us in the training, development, and feedback arena.  But, your team needs to see that you are engaged, that you are responsive, and that you are listening.

Dr. Charles Denham:  Thank you very much, Vicki.  Bill,, your thoughts any concluding thoughts on what you’ve heard Vicki say?

Chief Bill Adcox:  Well, first of all, thank you, Vicki, and I think that you’ve really recapped the entire workplace violence prevention approach and program.  The only thing I will say from a different vantage point is number one is we are looking very strongly at making workplace violence its own separate risk in our risk industry, meaning that’s how important it is.  And it should be that important to every institution.  Number two: the commitment has to be from your board and your CEO and your executive leadership.  They’ve got to voice it.  They’ve got to be behind it.  They need to be able to meet at least quarterly and discuss just nothing but workplace violence issues, where the program is at, how things are, and what can be done.  Then you have to have an ongoing regular group at a higher level, but a mid-management level that’s very much engaged.

And then all the way down to specialty areas that you’ve identified at your hospital or healthcare locations.  Where, where the more pro, where the greatest problem is, this is where, where being in a sophisticated program, you actually have the ability to do the metrics and ability to do the analysis and find out where, where are we having the most problems and what’s driving that so that you get to the, the root cause and develop some solutions for particular areas.  And then the other thing I would tell you is, as you know, we approach our work from the four Ps.  Its prevention, its preparedness, its protection, and then its performance improvement.  Now, thinking of it from the protection, this is again talking about a layering system.  So when we’re talking about workplace violence, you can be talking about everything from where you have passive weapons detection whether you have these systems in place, or there’s reporting that’s going on, whether you have your security personnel, you have your frontline personnel within the actual critical care or medical care, the clinical areas that are working all these layers.

Talk about your preparedness.  That’s, that’s when you’re going into this issue of everybody being on the same page. Vicki spoke very well about some of the different things that we have, and actually doing active shooter meetings and exercises at the, at the pod, at the clinical pod, at the, at the clinical areas with the staff at the time, very quick, very, very efficient.  And then you actually can test some of the systems that are in place.  But then there’s also the prevention.  And remember, we talk about the two types, Pacific types prevention, primary prevention.  This is where Vicki talks about identifying these, these, these comments, these behaviors of concern potential, so that you can have early intervention, you can have the multidisciplinary teams your behavioral intervention teams take a look at these multiple groups of cross-functional disciplinary groups that are looking into it.

So yes, you have that, that first level of prevention.  Then you have your secondary level of prevention, and that if something was to occur that there are systems in place through all the protection and so forth, where you can make a response, which really limits the damage limits, the, the, the problems that are occurring.  That’s where this active shooter prevention comes in.  This is where the active shooter responses teaching individuals what to do.  This is secondary prevention.  This is where we have our police component within our, our facilities, very much engaged. This is where you have the stop-the-bleed kits, the Med Tac comes into play.  How do you reduce the damage that’s being occurred and get things back to normal?  And once all of these things are in place, you’re constantly looking at how can we get better.  What’s the performance improvement?  What were the near misses?  What was the policy things that need to be readdressed?  And one of the things that you’re talking about today, and I’ll leave you with this, is this issue around definitions.  Definitions are, are going to be critical as we move forward to teach our employees.  And, and they’re going to be, and it’s going to be location to location.  When we’re talking about one of the things, talk about humiliation, humiliation this cultural issues in play.  

We’ve had situations where one of the evening shift people goes into a room to check on the patient.  The patient has to be of a certain faith, husband gets upset because someone gets to see his spouse in a different manner.   It’s a real problem.  Again, we’re talking about such a global issue with a bunch of different variables that we have to come to an agreement, what it is at the institutional level that we will consider as part of this, and what they’re going to be our responses in order to keep everybody safe.  Hospitals and healthcare places should be very calm.  They should be places where we’re going to do nothing, but, but looking at the quality of patient care, where we’re going to look at saving lives, and we’re going to look at comforting patients and loved ones alike and taking care of them.  So again I really appreciate it, but I do think the definitions are going to be critical.

Dr. Charles Denham:  So, thank you both so very much.  It’s been an honor for me to have had some of my training at Anderson, and you all are just doing a world-class job in this new area, which really is just an area of discovery.  And so thank you Vicki, and thank you, Bill.  I really appreciate it.

Chief Bill Adcox:  Our pleasure.  My pleasure. 

Dr. Charles Denham:  So, John, we’d like to thank you for hanging in here with us and really helping us bookend this with some focus on our leadership, our senior leaders chief operating officers, CEOs, and our board members who you have very a great deal of experience talking with.  I want to kind of we have a lot of them that join us and have joined us over the years.  John, your reaction to what we’re seeing with this broaden definition, what’s the role, specifically what’s the call to action to our senior leaders?

John Nance:  Well, it’s very simple.  Nothing’s going to happen without your leadership in an active way.  It is the same sort of thing that we’re seeing right now, and I won’t get off on this discussion, other than to say that most CEOs, most hospitals in the country over the last three years have been responding to covid.  Now, they’re using it as an excuse to not get involved in training anymore.  If the leaders, and that includes the board, don’t aggressively say, look, we have got to change this equation.  We’ve got to get in front of all aspects of it, and we’ve got to let everyone know that that, that violence, whatever form it might take, and as we’ve been talking about, it takes a lot of forms, will not be tolerated.  I, there’s just no way we’re going to tolerate it.  We might, you know, and we will hopefully work with a human bent and trying to correct behavior, but we’re certainly not going to tolerate it.

And that goes to the heart of the physician staff as well.  I can’t tell you how many times over the last 20 years I’ve encountered a hospital I’ve worked with, and there are a couple of doctors who are considered untouchable, then they throw things and they yell and they scream, and there’s just simply no excuse for it anymore.  A couple of things.  First of all, I don’t think that we’ve emphasized enough how important HR is in this equation.  As a matter of fact, I think that’s one of the most critical appointments that AACEO can make is who is in charge of HR.  Because if they’re just throwing rules at people then they’re ripe for the sort of situation that intimidates people because they’re not working with them.  If it’s, if HR becomes a pejorative, they’ve got all sorts of cap capabilities of being weaponized by unscrupulous people.

But if you’ve got a sensitive knowing, concerned HR director who is going to prevent that from happening and can, can discuss hotspots with the senior leadership that they can be the subject of intervention and intelligent intervention, that’s, that’s absolutely beyond the worth of silver and gold and whatever it, it’s something that absolutely is going to be required as we move forward, especially in periods of time where we’re in right now, where we’ve got massive shortages of nurses, massive pressures on people leaving, doctors leaving, et cetera.  We need a good careful HR department, not some, not one that’s going to be a police force, per se.  Now as far as boards are concerned, the buck stops there.  We all know that whether it’s a for-profit and the few for-profits we have relatively speaking around the country, or whether in hospital terms.

It’s the normal hospital that’s trying to do things on a an efficient and money neutral way, or at least making little the board is too often, pardon me, made up of people who are not savvy in medicine.  They may have been on that position for quite a while, but they’re usually put on boards because they have business experience and they have financial experience.  And sometimes it’s simply because they’re leaders in the community.  We have got to change this equation.  I want every board member in America to be shaking in their boots if they’re not doing the right thing because of the potential, a personal liability.  Now, I don’t particularly say that I’m a fan of a particular senator who came up with the idea beyond Sarbanes Oxley of putting Sarbanes Oxley on the backs of board members in healthcare.  But I’m to the point of saying, if it’s not going to be the mandate of the board to get things done in any arena, but especially in terms of violence and, and the response to it and in terms of not letting HR become a police force it’s got to be mandated by the board.  If the board can’t figure that out, then we’ve got to get people on there who can.

Dr. Charles Denham:  So, John, this gets at the heart of the issue of resources.  This is going to cost money, dark green dollars, cash, real dark green dollars.  And number two, it’s going to co-cost capacity, the light green dollars of operational staff when things are very short.  Your thoughts there on monetizing this and being able to argue this as a risk manager to the board and the CFO to say, this requires money?

John Nance:  Well, I think basically it comes down to this, what is a hospital there to do.  It’s a public trust.  And in fact, you have to have a license based on public need.  That means that you are not just taking care of the farm, so to speak, taking care of the hospital on its own.  You’re taking care of that community.  And if you’re not rising to the level that we know you need to be at then you’re not, you’re not in complying with your basic charter and your basic license.  Now, why that’s important is because if you’re not willing to spend the money for safety, for instance, for patient safety, if you’re not willing to spend the money for education on, on workplace violence and holding people’s hands as necessary to be able to get them to understand that certain protocols are simply not acceptable, then you’re violating your license.

We have been non-aggressive in this country about holding hospitals really to answer and to be responsible for fulfilling their obligation to the community.  And in too many instances with the billboards that are put up and the happy talk that goes around about how we’re the best hospital here, and we’re the best by that measure that doesn’t impress me at all.  I want to know how responsive you are in every single solitary way to the needs of the community that hasn’t been done.  I think that’s something else that the board needs to confront very definitely.  And that also impinges on everything we’re talking about today.

Dr. Charles Denham:  So, John, you, you know, you and I wrote an article years ago about an NPRA, national Transportation Board for Safety.  And you know, this idea’s been bannered around forever, but in, in essence, you as a, commercial pilot and me as a private pilot, both me much fewer hours, but both jet pilots and serious landing and serious places every pilot is a probabilistic risk assessment person.  You know, yes, you are looking at the risk threat vulnerability of any mission that you go on.  And so you’re an attorney as well.  So isn’t there enormous liability that’s been created by this new definition?  I would think that organizations, boards, and chief risk officers need to understand that if they don’t do this properly, they’re at risk for enormous consequences in litigation.  Is that a fair statement?  I mean, that’s what it looks like to me.

John Nance:  Well, it is a fair statement, but the problem is, and most boards don’t understand this, they don’t believe it.  They really think that their insurance policy, that almost all of them buy against liability, is going to save them from the hassles and worry about legal liability.  It’s just not the case.  And I think as time goes by, as we come to the reckoning, the fact that we cannot continue this non-system, as George Halverson once called it medicine in the United States, it’s got to change or it’s going to collapse.  As we look at what’s down the road, we’ve got to expect responsibility and professionalism from our boards.  Yes, I realize, and  I’ve dealt with and worked with so many people on boards.  There are fine, upstanding, wonderful members of the community trying to do their best, but it may be time, as I say, to get professional board members in there who understand that they’re liable, but they also are paid to do a job.  Right now, it’s all voluntary, and it’s just not worth it.