Workplace Violence in 2023
A threat to Caregivers, Staff, Educators, and the Community

February 16, 2023

Speakers and Reactors:

Dr. Charles Denham – Moderator
Assistant Chief Vicki King
Dr. Gregory Botz
David Morris, PhD, JD
Dr. Casey Clements
Chief Bill Adcox
Randy Styner
Jennifer Dingman

Dr. Charles Denham:  Welcome to our program today on Workplace Violence in 2023. I’m Dr. Charles Denham. I’ll be your MC today. I’m the Chairman of TMIT Global. We’re delighted to have you with us. This is our 200th monthly webinar.  Hard to believe that we’ve had that much experience with this and such a great audience. For those of you that are on the podcast, you can go back to you can go to our website at to download the slides and watch the videos. We’ll add resources, articles, and other things to keep the topic fresh. This is the first of a series of programs that we’ll undertake on workplace violence. For those of you who want to download the slides, you may also do so by going to our website.

We’re very blessed to have Jennifer Dingman, who will be with us. In case her internet connection was not great, she recorded her opening for us, and she’ll be with us as a reactor as well. Jenny is a longstanding patient safety advocate. We’re almost at 200 months in a row that we’ve run these webinars, and for many of them, she was the opening speaker. We always try to have somebody representing a family, a patient family that will help us focus on what we are to do. She’s got kids, she’s got kids that have been students. This is a major focus area for us. So we’ll have Jeni open us.

Jennifer Dingman:  Thank you for your kind introduction, Dr. Denham. Today’s program is very, very important. Regarding workplace violence, we’re seeing an increased number of violent acts at workplaces, particularly hospitals, healthcare facilities, and other places where people are trying to help other people. I’m very, very excited about listening to today’s program, and I thank all of you for coming. Please share this program in the recording with all of your friends, colleagues, and family members. I’ll hand it back to you, Dr. Denham.

Dr. Charles Denham:  What I thought I’d do is just start off with a video to really kind of set our stage here. 

Video:  I’ve been hit, punched, bitten, kicked, scratched, called names cursed at, even choked.

Too many nurses and health professionals have suffered violence at work. It happens in hospitals, nursing homes, treatment centers, and other facilities every day. And the attacks can come from patients, family, or other visitors. This kind of violence is preventable. In 2016, 70% of non-fatal workplace assaults occurred in the healthcare and social assistance sectors, and nurses were often the targets. In fact, healthcare workers are nearly five times more likely to be assaulted than the rest of the American labor force. And workplace violence is getting worse in the last decade. Rates of violence rose by 123% in hospitals and more than doubled in psychiatric and substance use treatment facilities. It won’t get better unless we do something. Nurses and health professionals are fighting for policies to make our hospitals safer for ourselves and our patients. We are speaking up to say, violence is not part of the job. Help us prevent workplace violence. Tell your legislators that nurses deserve to be safe at work.

So, this program is dated. And we know that the problem is even worse. Now, I’m going to go through some preliminary information to get us started. We’ve got great speakers. You may go to our, so social media addresses, which you’ll see in our slide deck. And j very quickly, the purpose of TMIT Global, Which I founded in 1984, so we’re almost at 40 years. Our purpose is that we will measure our success by how we protect and enrich the lives of families, patients, and caregivers. Our mission is to save lives, save money, and create value in the communities we serve. And we try to live our core values, and I’m sure we fail every day, but we make a great attempt at focusing on our behaviors of integrity, compassion, accountability, reliability, and entrepreneurship.

You may look at slide six for our disclosure statements. None of our speakers have anything to disclose. And TMIT Global has never been funded by industry, or by pharmaceutical or device companies. No direct, indirect, or affiliated financial support has ever been or ever will be provided by healthcare, pharmaceutical, or device companies. For those of you that are with us for the first time the TMIT Global Research Test Bed, as I say, was launched almost 40 years ago. Over time, over many, many projects, has aggregated about 3,100 hospitals in 3000 communities, and 500 subject matter experts from clinical, operational, and financial areas who contribute their time and energy to us. I’ll only mention our Coronavirus community of practice to acknowledge our speakers today. Our three live speakers actually were great contributors.

We ultimately ended up with 160 subject matter experts and produced 30, 90 minute programs that are available on our website. And we’re especially delighted to have a great young adult team ranging from high school students right through to graduate school for many of our leading universities who are contributing to our MedTech program, our medical tactical program to focus on failure to rescue for the most common medical emergencies that bystanders can, where bystanders can have a role. Before e M S arrives, we undertook a 1000 worker study over the 30 month period, and it continuously informed our work, and now it’s informing our work in this area that of preventable harm and failure to rescue. So we have a series of 10 articles. Six have been published in the journal for healthcare, faith-based and higher education organizations.

Campus Safety Magazine. One is on active shooter, the other is rapid response teams, and the other is an ED and bleeding control gear placement. And our last webinar, we addressed the preventable and unanticipated harm. And today, workplace violence has grown so much that it actually has now expanded far beyond just physical violence of an incident, of a single incident. I want to draw your attention to those on the podcast. That we have a fairly complicated chart here that shows the unintentional death from data from 2013, and it was published by the National Safety Council in 2016. And then we have constructed a similar graphic with their data from 2020, which shows an enormous increase in opioid overdose. And so, please come back to watch some of our programs on o on that, and we’ll be covering drug diversion in hospitals and other things.

But we cover each the areas that are the most common causes of unanticipated harm and death. The problem is failure to rescue. And on a slide, for those that are on the audio and, and podcast, we address eight leading causes of death and the concept of failure to rescue. And now we’re talking about workplace violence and really failure to rescue from that. We work with a number of as many national organizations as we can to provide free training. We never charge for training for these areas. And finally our Learning Management System, which will issue if you’re nurses or physicians, continuing education, documentation, and certificates. We start with a community of practice, and we work and learn together.

We develop courses, we develop competency testing and then certifications and incentives. And that’s what we’ve done with this era, this program called Med Tac, which we won’t cover today. And Chief Bill Adcox will address how we tackle the four Ps, prevention, preparedness, protection, and performance improvement as we talk about workplace violence. And before Covid-19, Bill Adcox, who’s with us, the Chief, Dr. Gregory Botz, and Randy Styner, and a number of our leaders helped us establish a community practice of emerging threats. These are 30 emerging threats that should or are keeping leaders of medical centers up at night, but we’ve expanded it now to higher education, and we’re expanding even further to schools.

But of the 30 topics, one of the topics was workplace violence with a definition that was pretty limited. For those of you that want to know more about this community and practice, you can go to our website at and watch a video regarding that topic. We focus on inside and outside threats, the threats and vulnerabilities inside, and the threats and vulnerabilities we have to outside threats. And the goal is not that we believe that we can remove all threats to workplace, workplace violence, or any of these threats, but that we can increase resilience and that we can increase a zone. So, on the slide I’m showing now for the podcast, I showed the 30 areas that we’re focused on for these emerging threats, and one of these is workplace violence.

Now, you’ll hear a lot more from Dr. Casey Clements and from Vicki King, so I won’t steal their thunder. But the expanded definition from what all of us thought of workplace violence to be physical assaults to our staff, and an individual act or a set of acts, has now been expanded dramatically. So, if we looked at workplace violence before this community of practice was launched, in the recent development of this new definition, it was one of our 30 areas. But now, with the expanded definition to verbal and non-verbal and intimidating and harassing, humiliation, humiliating words, bullying, sabotage, and for those of you that are on the podcast, we’ve got this definition, which Vicki King will address, and I’m sure Dr. Clements will also address. This dramatically expanded the vulnerabilities and the target areas. And now, in our emerging threats community of practice, it covers many more of these sturdy areas.

We’re focused on violent acts against leadership, insider threats, intentional harm to patients, financial harm to patients, defamation or unfair press, preventable death, or a severe injury. And really, all of these can impact our brand. So with that brief introduction, I’d like to go to Vicki King. Vicki King is the Assistant Police Chief working with Chief Adcox, who’s with us live today.  Vicki is on vacation today. She was gracious enough to prepare an entire presentation for us which I’ll stream now. We’re so grateful to have her share her time with us. For almost 30 years, she has lived in Houston. She’s done international work. She has a master’s in criminal justice. She is one of our leading-edge academicians, meaning that she’s really teaching us an awful lot about the threats and many of the threats far beyond active shooter events. And I’ve asked Vicki to give us a foundation. This is the first of a number of webinars that we’ll have on workplace violence. But we really wanted to get a level set of a foundation. And then we’ll ask Dr. Casey Clements from the Mayo Clinic to build on that. So I’m going to now turn it over to Vicki King, and we’ll have her address this foundation of knowledge.

Assistant Chief Vicki King:  Good morning, everyone, and thank you for the opportunity to talk about this extremely important subject of workplace violence. We want to begin our discussion with a level setting where workplace violence is in the healthcare community in 2023. And what we have found may be shocking to many of you, and it is a constant and pervasive threat to caregivers, staff, educators, in fact, the entire community. And so today, we want to examine workplace violence within our healthcare community and do more than raise awareness. We want to have a call to action. To give you an idea of our background. I want to give credit to my colleague and mentor, Bill Adcox. He is the Vice President and Chief Security Officer for MD Anderson and UT Health. He and I work together. I’m over the investigative operations and threat management team for MD Anderson Cancer Center, UT Health Science Center in Houston, and the Dunn Behavioral Health Center, which was just recently added as one of our hospitals and the Harris County Psychiatric Center.

So, we see many of these cases walking through our doors, and we want to share with you some of the insights and approaches we have to workplace violence. But we have to begin with our triage. But what’s our current state? What’s our present condition? The numbers collected by the federal government are not as recent as we would like them to be. But when we look at it, this has been a pervasive problem for quite some time. In 2019, 8 in 10, about 80% of our emergency department physicians said that workplace violence within their care setting is increasing. And of those, more than half say patients have been physically harmed while in their emergency department. Nearly half of emergency physicians themselves have been physically assaulted while at work. And more than six in 10 of those assaulted say that assault occurred just within the past year.

So, nearly seven in 10 say their hospitals reported the incident, yet three per, only 3% of those assaulted press charges. And that’s a significant problem within our community in that some view being a victim of workplace violence as just part of the job. And I’m here to say that, no, it’s not. Our provision efforts begin when we take these issues seriously and work to curb future violence when we stand together as a community and take proactive action. When we look at healthcare workers as a community, the Workplace Violence Prevention, Healthcare and Social Services Act wants to address this. That’s the proposed legislation after OSHA issued a report that said healthcare workers accept 50% of all workplace violence assaults. Now, some of the data is, is not as fresh as we would like, so we get some of our data from surveys. For example, the US Bureau of Labor Statistics surveyed healthcare and social service workers, and they found that the highest rates of injuries were caused by workplace violence. And just in 2021, they revised their findings to say that healthcare workers are five times as likely to be injured because of workplace violence as compared to other workers.

In 22, there was a survey by the National Nurses United, which is the largest union of registered nurses, and 48% of the more than 2000 responding nurses reported an increase in workplace violence, more than double the percentage from the earlier year. So it’s on the rise. And we all know how Covid has impacted our healthcare community in ways we never expected. So let’s look at the definition of workplace violence. We’re going to take this from the Joint Commission definition, which simply says workplace violence is an act or threat occurring at the workplace. That can include any of the following, verbal, non-verbal, written or physical aggression, threatening, intimidating, harassing or humiliating words or actions, bullying, sabotage, sexual harassment, physical assaults, or other behaviors of concern involving staff, licensed practitioners, patients, or visitors. So it’s a pretty comprehensive definition that allows us, with this broad definition, to look at the sources and intervention strategies associated with workplace violence.

Now, how did we get here? The most important thing is that we have to remember the impact on those people who have paid the ultimate price for being healthcare workers and serving our community. You see just a few of the faces here. Lynn Trillo was an emergency department nurse at work when, another nurse was attacked by a homeless man Jesse Gillary in the emergency department. And she did what many of us would do. She’s sprung into action. Our nurses are on the front lines; they know how to protect. And she ran to the aid of the colleague. Gillary attacked her and threw her to the ground. She suffered a torn ACL. And amazingly, she completed her shift, but she knew that something was wrong. She went and sought medical treatment the next day and was scheduled to have surgery, but before she could get the surgery, she threw a blood clot and died as a direct result of the assault she received in her emergency department.

But she isn’t the only one. We had a CAN, Ray James. He was killed by a coworker who had mental health issues. He was sitting at a desk doing his job. He had no interaction with this worker, no grievance with that worker, and the worker was delusional and attacked him, and killed him in the workplace. I worked on Dr. Mark House, connecting the forensic review of his case, the fascinating case study. Those of you who might be interested, I’ll be glad to share it with you. But Mark was assassinated riding his bicycle on Main Street on a Friday morning by the son of a patient who tragically died during a procedure Dr. House had conducted. And the grievance for that case was 21 years in the making. Seems incredible. But he was murdered at the Texas Medical Center on Main Street.

One of the most compelling case studies is Dr. TA O’Neill. Dr. O’Neill was a victim of domestic violence. She separated and called off her engagement with her fiancé. He came to the workplace to confront her about returning an engagement ring. She went out into the parking lot to keep his aggressive behavior away from coworkers. A friend tried to come to her aid, and her fiancé shot and killed Dr. O’Neill in the parking lot. A police officer was passing, saw the assault chased the suspect, and he, the suspect, ran into the hospital. When he entered the hospital, a young pharmacy tech exited the elevator, and he shot and killed her without any reason or hesitation. He also shot and killed the police officer who responded to assist Dr. O’Neill and her colleagues, A tragic event. Still, it demonstrates how workplace violence, these domestic violence situations can spill over into the workplace.

Mental health technician Cassie Dewey was another one. She was killed by a coworker who was a boyfriend. He had a romantic relationship with a fellow employee at their hospital and engaged in domestic violence. The hospital knew about that incident but didn’t relieve him of duty or try to manage that assault behavior. And Cassie unsuspectingly entered into a relationship with him. It immediately went bad, and she was killed outside of her home, leaving a young child. And then, of course, there’s Dr. Albert Burt Goodier, who was killed by a patient upset over a diagnosis. Thankfully, these types of tragic events occur not often in fatalities, but the assaultive behavior begins in the hospital and, left unchecked, can result in a tragic end. And so we want to share with you, in their memories, some actions that we can take to help prevent those acts of violence from escalating.

And we get assistance from our accreditation and standards organizations. CMS is the first one, and CMS talks about the patient’s right to receive care in a safe setting. And it requires that the hospital complies with all federal, state, and local emergency preparedness requirements. So CMS sets level. It’s the governing body for all hospitals across the nation. We also look to OSHA for its guidelines. OSHA has one of the most complete guidelines for workplace violence that they issued just a couple of years ago. It’s still fresh, violent, and viable for you to look at. It’s a great starting point, but it also serves as the foundational event for a Workplace Violence Prevention Act for healthcare and social service workers. This legislation passed the House with 228 co-sponsors and currently sits in the Senate. The legislation calls on OSHA to issue a standard requiring healthcare and social services employers to develop and implement workplace violence prevention plans to protect their employees.

It also protects not just the staff but also the visitors and patients who come into the facilities seeking help. The most recent is the Joint Commission Accreditation Standards. And we’ll explore these in a little more detail in this next slide. So, four revisions or new standards were applied, and they took effect in January of last year. First and foremost, you have to have a designated leader, a single point in our hospital Bill Adcox, our Chief of Police and Chief Security Officer, is our designated leader. So the hospital has this workplace violence prevention program, and you have one person who’s your standard bearer responsible for bringing it and is the face, a place, and a person that people can identify with and go to helping to help advance workplace violence prevention initiatives.

The second is to have an annual worksite analysis. So, the hospital needs to conduct an annual review of its workplace violence program. And this is designed to identify hotspots in your community of care, whether it’s your emergency department, ICU, in any of your pediatric units, or palliative care or hospice care outpatient services. You identify, through the data, places of vulnerability and have specific actionable plans that you will enact to mitigate, reduce, or eliminate that violence. And then most, we all know that training is essential. The hospital needs to pro to provide role-based training. And that means that the hospital provides education and resources, and training to leadership-licensed practitioners based on what they do in the hospital. What are the expectations? Because we know that frontline nurses and doctors may have different vulnerabilities and different challenges than, say a receptionist or a scheduling assistance. Looking at all aspects of the hospital and finding out where you are regarding vulnerability and what skill sets you need to mitigate those vulnerabilities.

Let me back up just a second. On a role-based training, the most important thing is that everyone needs to know what your prevention program is? What’s your strategy? How to recognize behaviors of concern and respond to those, including reporting workplace violence. And so that brings us to the last segment, the reporting, and investigating. Once people know how to report, they need to know that the hospital will take action when they investigate and develop strategies to make the workplace safer. And from a morale and effectiveness standpoint, this particular aspect is most important. You must create those feedback loops that your team if they entrust you to report. And we know that workplace violence is extremely underreported. They want to know that the hospital will do something and that the efforts will be designed to make the workplace safer.

So how do you approach that? That is a huge issue with many hospitals. We all have competition for resources, and we work on some of these extremely complex issues. We must provide care even to some of the most problematic segments of our society and some of our patients. So, let’s talk a little bit about workplace violence and how it can impact, and I’m just going to give you a couple of quick examples. We worked on this case. It was a 24-year-old first-generation Middle Eastern female researcher. And her parents were very traditional and did not approve of her adopting a more Western non-traditional lifestyle. They had very specific curfews for her and didn’t want her unaccompanied in the presence of men who were not family members. And when she began to date someone, her father and her brother said that they would rather see her killed than suffer a dishonor of her engaging in what is socially acceptable in Western culture.

So, our team worked with her and developed a mitigation and safety plan for her, her boyfriend, and close associates. Honor killings do not simply hit the target. Sometimes they will hit those who they believe are negatively influencing the loved one to stray from what is believed to be their pathway to eternity. The family is battling for her soul. And so, there are cultural implications of this issue, but also emancipation issues for the 24-year-old female who wants to go on and live her life. So we worked with some of our cultural experts to help us develop a strategy that could reach the family, speak to the honor, and comply with the laws of the United States. We were able to have a mediation between the family members, the student, and some of our cultural representatives within the community.

And from that aspect, we were able to reach an accord. You know, it may become strained again in the future, so it’s constant monitoring, but what it did was stabilize some of the high emotions that were running rampant. It allowed us to level set and respect the religious beliefs of the father and brother, but bringing them into our laws and expectations for residents of the United States was an extremely complicated case. I’d love to go into it some more at a future date, but somebody to say that sometimes just reaching out and having an opportunity to communicate respectful communication that doesn’t judge the family beliefs or the 21-year-old desire to go on with her life in a different aspect. Those are some things that don’t cost a lot of money.

There’s something that you can do within your community, and it is that multidisciplinary approach to address a problem but also to bring about a positive and right now, sustainable safety plan. So sometimes, within the workplace, flirtatious conduct and inappropriate sexual advances if they are ignored, we see that there’s a tendency for the bad behavior to escalate in both severity and frequency. So we encourage early reporting. In a particular case we worked with, a female nurse felt like she was handling unwelcome advances by a coworker. Unfortunately, when someone doesn’t understand NO, those bad behaviors have a tendency to continue and to grow. And that’s what happened here. It grew into an assaulted behavior with the man grabbing the nurse’s breast. She immediately reported the physical assault and action was taken to terminate the aggressor.

After the situation was investigated and found to be sustained, he received criminal charges. But more important than the law enforcement aspect is the safety planning for the nurse, the unit, and the witnesses who came forward in that case. Those are essential components of the comprehensive approach to workplace violence prevention. What you don’t want to see is because someone takes criminal action that we think everything’s okay or someone is terminated. So they’re no longer on our campus. So everything’s okay. We want to make sure that there are mitigation plans in place to protect the workforce in the wake of these events. And they go from emotional distress. And another opportunity, you can have counselors who can come in for critical incident debriefings. But the important thing is that the workforce knows that you’ve given criminal trespass warnings, protective orders, and that you have security at the entrances that know who this person is and alerted, should they come.

There’s some monitoring of the person outside who is terminated, escorts for the nurses and the units to and from the vehicles and, monitoring of social media aspects that may indicate that there is a desire for retribution by the person who is terminated. Those are all aspects that need to be managed in the wake of these kinds of events. 

And then we know that patients and their family members have stressors outside of the healthcare environment that they bring into our setting as part of their life. And in this particular case, we had a 52-year-old mother who was approaching the end of her life. Her adult son was at her bedside. Her primary caregiver throughout the mother’s disease progression had been the mother’s sister, and she had medical power of attorney and was making the decisions for the mom.

As she neared the end of life, the mother’s adult son expressed discontent with the aunt’s decisions and some of the care team approaches to his mother’s deteriorating health. He became enraged. He was speaking to his aunt over the phone because she wouldn’t be in the room with him, and shouted over the phone for her to bring her gun so that they could settle this matter. So naturally, the care team was very concerned that there could be an escalation, that there could be a physical confrontation or a violent confrontation within the healthcare setting. And so many hospitals have moved to a zero tolerance for workplace violence, and zero tolerance for workplace violence is a good thing. But that does not mean that you automatically respond with the exact same response.

So let’s talk about zero tolerance for just a second. We don’t tolerate that type of behavior within our healthcare setting. This young man was removed from his mother’s bedside by officers who came, and they talked to him about the hospital’s stance that we don’t tolerate that type of behavior. But here we have a woman who is nearing the end of her life. And some of the things that we become concerned with is this adult son who has poor impulse control of violent criminal history, and is in a feud with his aunt, that grievance could be transferred to the hospital. That he holds the hospital responsible not just for the treatment of his mother, but the denial of end-of-life visitation with his mom. That denial of end-of-life time has frequently become enduring. It will become a center point for that person and justification for future acts of retribution.

And what we wanted to do was to make sure that that aspect of the grievance did not take root. So we began to work with the son and talk to him about his behavior, how his behavior frightened the staff, created a disruption to the care of not just his mother, but other patients in the area, and reasoned with him and worked with him to have supervised visits with his mother as she neared end of life. And I will tell you that that was the single most important thing to dispelling his grievance against the hospital, being able to work with him, being able to give him time to arrange for a final goodbye and have him share that experience with his mom for a few hours. I will tell you that our hospital staff was concerned. And so, the importance of having a uniform presence as well as plainclothes officers who interacted during that window when the sun said his goodbyes was essential to maintaining and letting the staff know that their safety was paramount, but also explaining to them the importance of keeping the son from becoming angry with them and potentially retaliating once his mother had had passed on.

So, communication with the staff, letting the staff control when the visitation occurred, having the staff control the duration of the visitation, and having staff know that they were protected by the institution with a safety plan, both during and after the event, helped bring this situation to a successful conclusion. So when we talk about threat intervention, it’s truly a multidisciplinary approach. The cases come in at the top of the funnel. We identify a behavior concern or an issue. We begin our inquiry and investigation. We drill down, find out as much about the person of concern and their grievance, and what the issues are, and the safety concerns and the staff and those around the staff. We assess the level of risk and the potential for workplace violence, and then we manage that risk. As the situation changes, we again go back and identify the new concerns, conduct our investigation, and continue this loop until the behavior is either mitigated, resolved, or neutralized.

And so, when you talk about the roles of a threat assessment team, we have people from our healthcare community who sit on this team. We have a permanent core, but we also have subject matter experts such as psychiatry or palliative care, or community members if there’s a cultural aspect to it, who come in and share with us, and help us gather all information to understand the situation as best we can, to determine the level of potential threat whether or not the person of concern poses a safety threat. And then offer reasonable and thoughtful management recommendations. How do we approach this unique situation with, not cookie cutter, but a unique approach designed to mitigate, reduce, and neutralize that threat? And this is what our intervention model looks like.

On the left, you see the reported incident, and it can come from any facet. We receive them from multiple sources. As a team, we work together to gather information as a team. We come together to assess that information for potential future violence. We, as a team, develop a mitigation and intervention strategy. And then, once that intervention strategy is applied, we evaluate it. We see if it’s successful, we tweak and retool if necessary, and then we continually monitor until that risk has returned to baseline or been neutralized. So together, what does a good ‘best in class’ workplace violence prevention program imply? It uses high-reliability principles. Centralized reporting and data collection are essential. You use data-driven decisions to improve your outcomes. It is a prevention-focused goal with training that supports your goals and becomes the model for accreditation standards. And the outcomes are amazing, a positive impact on patient experience and care. You approach that zero harm, you enhance your zero harm impact, you enhance organizational resilience, and of course, brand protection. There’s this collective mindfulness for safety, because we’re all coming together as a team to do what’s right and to do what’s safe. And then as an institution, you become an employer of choice. It enhances your recruiting and your retention capabilities.

I know it’s a lot and I know it seems daunting, but Steve Jobs said, the ones who are crazy enough to think that they can change the world are the ones who actually do. And we, as a team coming together, we can work collectively to make our healthcare settings and our healthcare teams safer, more productive, and more importantly, they can give back their unique tools and their unique abilities to protect our community and to make us all healthier and safer. I know this has been a lot. I hope I didn’t go too quickly for the team, and I invite any questions.

Dr. Charles Denham:  Thank you so very much, Vicki. What a terrific level set and really helping us get started in this area. I know a number of our audience are representing smaller hospitals or groups of small hospitals. You’re MD Anderson. I have the honor of training, taking part of my training there and working with you and Texas Medical Center. And the first thing people always say is: the Mayo Clinic or MD Anderson have all the resources. How can I do what they can do? Can you give us some tips as to how one might get started at a typical 300 bed hospital that is in a community doing their best?

Assistant Chief Vicki King:  Yeah, absolutely. All you have to do is get some training. There’s free training available through the Association of Threat Assessment Professionals. There’s also great training available through these types of webinars. And from collaborating with colleagues such as myself, and we’re glad to help where we can, but then form your own team. It’s an hour a week. Set aside, one hour a week to have those more problematic cases bubble up to your unit, and to sit together as a team and work through the problems when you need some additional assistance, say from law enforcement, have those relationships established. Go to your chief of police in your small community. You are a critical infrastructure. Let them know that you need their help on these events so that you can keep, the entire community safe. Most police chiefs would welcome partnerships.

Maybe they would even have one of their investigators sit on your behavioral health team one day, one hour a week, and look at some of these more problematic cases. That level of engagement, that level of multidisciplinary approach, will help you work through some of these more problematic issues. You can always have consultants or have practitioners in the field come in and say, Hey, look, we’ve had a similar situation. This is how we approached it. This was either our positive impact, this is how we were able to mitigate the issue, or this is a lesson learned. We did this and, wow, that didn’t go as expected. So learn from us. So those are some things. Collaborate and form your multidisciplinary team. Establish relationships with colleagues who may have some information or some expertise in the area, and leverage that information to make your workplace safer. I’m going to tell you just by the simple fact that your team knows that you formed a multidisciplinary team dedicated to workplace violence prevention, and that you circled back to them forming a feedback loop to let them know they’ve been heard and you’re working on it. That will do so much to advance it.

Dr. Charles Denham:  Fantastic. So that what a great answer. Next question is, typically you don’t have a budget for new things. And all of our facilities are constrained, especially our smaller or mid-size hospital systems and, individual hospitals. How do you make the case, or what would your three big points be to tell the bosses I need resources to get going here?

Assistant Chief Vicki King:  Well, first and foremost, workplace violence is a resource drain. Whether you recognize it or not, you’re going to lose time from people who decide that this is not a safe workplace and they go somewhere else. So, retention, recruiting, we’re all short-staffed, so you will give the reputational harm. But more importantly, it is the uncertain worker’s comp cases with a physical injury. But more importantly, it is going to be a drain on the ability to provide service for you to carry out your core values, your core mission to the community. Workplace violence undermines everything you do, including your financial stability. So not investing in it is going to be more costly than addressing it, at least with some fundamental first steps where you take staff who are already on the payroll and carve out that hour or so a week and provide them with some training so that they know how to recognize the behavior of concern. What’s the pathway to violence? What’s the difference between effective violence and targeted violence? And how do you approach those? So many times we invest money in target hardening, so we have more security guards, we have metal detectors, we have all those things. Those don’t address the human factor of how you stop some of these workplace violence incidents through identification, communication, and mitigation of it. And then of course, always those feedback loops. So you know, if your mitigation strategy was effective and staff are being heard, those don’t cost a lot.

Dr. Charles Denham:  Fantastic. Now, with the changes that have occurred over the last, say, four or five years, this has required some policy changes in the organization. Any tips there? Many of our organizations have been through covid, they’ve been stretched, they’ve had to kind of bend or even break policies to get through it. And any tips on getting those policies changed rapidly?

Assistant Chief Vicki King:  Yes. The most important features of any policy is to define workplace violence. And I encourage you to use OSHA’s definition or the joint commission’s definition. Homeland Security even has a definition. Put those definitions in, educate your community what they are, know what the reporting mechanisms are. If you don’t have a strong unified reporting mechanism, you’re going to miss those events that need mitigation or need action.  Encourage that reporting by your staff, and they will report more if they know that you’re doing something about it. So put in your processes, the definition, the reporting structure, how you’re going to approach it, and the feedback loops, and to identify through the data where your points of vulnerability are and put your resources there to keep those places as safe as possible. Those are some of the things that the policy needs to address at the outset: that, with the data you collect, you have to do an annual site assessment for the joint commission if you’re one of those hospitals that are joint Commission accredited. So look at the data and find out where your vulnerabilities are, and then have a strong action plan for addressing it.

Dr. Charles Denham:  So last question. You are so talented and so impressive as a communicator; I will never forget first meeting you and helping you and having you describe this process of de-escalation. Can you tell us how valuable it is for all of us to learn de-escalation?

Assistant Chief Vicki King:  De-escalation is the primary tool in your tool belt to help prevent violence, even if a violent event has occurred to slow it down and deescalate. Sometimes if you can just calm the person down, remember, they’re functioning at an emotional level, so their senses don’t work the same way. You’re not going to appeal to someone who’s in an emotional state with logic and reasoning. What you have to do is appeal to them at an emotional level and say, it’s okay. It’s going to be okay. I’m here to help. Let’s work through the problem. Let’s just slow it down. And to start training your staff on that communication. And don’t argue with someone. You can’t; even if you’re right, it doesn’t help. When you’re right, it sometimes makes things go the opposite direction.

So what you do is teach your staff how to connect with that person and tell them you’re going to take them to a place of safety. You’re here to help. I’m hearing you. I hear you. It doesn’t mean you agree with them. I hear you, and we’re going to work the problem. We’re going to work it out. I’m here to help. I’m here for you. And when you start connecting with the person on that emotional level and bringing them down, that’s how you then begin to work on the logical aspects of the argument. But training your staff how to take a critical incident and know how to respond. If it’s an acting shooter, you’re not going to, de-escalate that particular situation. So, your staff needs to know where their safe zones are. What are your expectations? How do they keep themselves and the patients safe?

How do they deny access? How do they fight? And what tools do they fight back with if that becomes necessary? We are doing unit level where we take our team into the work unit, spend 15 minutes with the staff, walk the unit with them, and say, okay, if an active shooter occurred right now, what would you do? And we talk through where they would go, how would they deny access to that particular unit? How, where would they hide? How could they lock secure patient rooms that don’t have locks on them? What are some of the things that they can do to help protect themselves and others while help is on the way? Just acknowledging that is a sad but true aspect of what we have to prepare for in today’s environment is so meaningful to the staff because they know that you are taking their safety seriously, and you are coming to them to talk about it. You may not have all the answers, but letting them know you care can yield so many positive results. And it also engages the staff because now they’re going to be an active partner in their own safety, and that is huge.

Dr. Charles Denham:  Vicki, thank you so much. And we want to have you back to tell some of those de-escalation stories that are so powerful in memory, etched into my memory. We’re also going to be building the business case to help communicate to boards and the C-Suite and CFOs why it’s important to put good solid resources, dark green dollars and light green dollars there. And we’ll be doing that in the future, and I know we can count on you to help. Have a wonderful vacation, and thank you so much for your help.

Assistant Chief Vicki King:  Thank you. Take care. Bye-Bye.

Dr. Charles Denham:  Dr. Botz, thank you so much for sharing your thoughts today. So from a clinical perspective, is workplace violence as big a problem as we think it is?

Dr. Greg Botz:  Yeah, it absolutely is. I think we’ve been focusing on that part of the iceberg that we can see above the waterline, but there’s much more below the waterline that’s affecting our clinical activities. It’s affecting our patients directly because with workplace violence, our team performance suffers. And we know that if we have caregivers that are distracted or affected by the emotional or physical effects of workplace violence, their ability to take safe care of patients is degraded. And so, absolutely, it’s a problem and it’s a growing problem.

Dr. Charles Denham:  Dr. Botz and I’ve had conversations about this expanded definition now that has been put forth by the Joint Commission that goes far beyond physical violence. Your thoughts?

Dr. Greg Botz:  Well, I think the definition that the Joint Commission is using is fantastic because it expands the boundaries around workplace violence to include those non-physical or non-direct threatening aspects in the workplace that can affect the performance of our caregivers. And that includes things like harassment or things that might impair someone’s ability to either promote or get expanded work responsibilities. And that is a detriment to our workforce.

Dr. Charles Denham:  Final question, do you think our leaders really need to dig a little bit deeper than just a definition like this and understand how these typical scenarios might develop in their hospitals and in their healthcare systems?

Dr. Greg Botz:  Well, I think so. If your organization strives to be a high reliability organization like mine, then you need to look at all of the dimensions of the team members in order to optimize performance, to reduce waste, increase efficiency, and to improve patient safety, which is our ultimate goal.

Dr. Charles Denham:  Well, thank you for your comments. We’re going to have a second and a third program addressing this this problem. And today is a level set—so, many thanks.

Dr. Greg Botz:  Thank you.

Dr. Charles Denham:  What we’ll do now is actually go to a terrific contributor to our program over the last a few years. David Morris is not only an attorney but he’s also a forensic psychologist, and he has a PhD in forensic psychology. He’s a leader who helps many, many organizations with workplace violence. Interestingly, he in his seventies and is reportedly the oldest MBA student. He’s in the MBA program at Yale, while he continues to do a tremendous amount of work in this area of workplace violence, and has been an advisor regarding a number of events that have occurred the last month that you’ve seen on the national press. However, we won’t be covering those. And so, we’ve asked David Morris to make a few comments regarding this issue.

David Morris:  Yeah, so Yale is an exciting opportunity to learn. And I say that sincerely. Every day I go to class, I feel like I’m 18 years old again, and I’m learning so much that I didn’t even know. You know, it’s that element of knowledge where I didn’t even know it existed. And I’m so fortunate to be there. It’s an incredible institution, and I’m, and I say that sincerely. It is really special. It’s a special place. And, you know, the, it’s like gestalt. It’s the hold – is greater than the sum of its parts, no question about it. But the magical part is the people, the students you meet, and the faculty. They are the pure magic of Yale. Really. It’s truly an amazing place. I’m glad to be there.

Dr. Charles Denham:  David, we’re so grateful to have you comment on workplace violence. From your perspective, is it as big a problem as we think it is?

David Morris:  Yes, Chuck, it is. It’s as big and it is truly a crisis that we’re in. And what’s really disappointing and, shocking is that what we’re seeing is only the reported. There’s a lot that’s not being reported. So it’s really the tip of the iceberg. The, the problem is much bigger than the data actually even reflects.

Dr. Charles Denham:  David, you’re a forensic psychologist, you’re getting your MBA, and you have a JD, so you have a rare perspective here on this. Are there opportunities to use psychology and practical psychology to tackle this problem?

David Morris:  Yes, there is, and we’re learning more and more about it. All of my disciplines that I’ve been fortunate enough to study tell us that in fact, it’s not just physical violence, it’s assault under a definition if your person feels threatened or uneasy. And then I love the definition that has expanded it so that bullying is included. I mean, really, those are all the elements that should be included in the definition of violence at the workplace.

Dr. Charles Denham:  David, today we’re just really establishing a foundation of knowledge. Do you believe that there will be practical tools of screening and psychological assessment and things that we could actually put in place in our frontline hospitals? Do you think that there’s a future there?

David Morris:  There’s absolutely no doubt. Once we identify the problem, that’s the first step. You’ve got to identify and recognize and acknowledge, we have a problem here, and it’s really a real crisis, then the science will begin. It’s a challenge, we need to be a little patient with it. But I know that it can’t wait too long. The research is coming out. We are seeing that, in fact, assessments of people ahead of time can predict a quick assessment of people and can predict their propensity for violence, under the new definition,

Dr. Charles Denham:  And David, is it not true that there’s a great overlap between workplace violence and insider threats? That we do have a house to clean up on the inside and many of our industries?

David Morris:  Yeah, absolutely. In fact, I was recently talking with someone that was working in hospitals in, Mexico, and after talking with him a while, he said, I believe there’s an overlap between insider threat and workplace violence. And I was really surprised at his insight. And I said, absolutely. The metrics we’re using to assess a particular insider threat can be broadened to where you’re just getting a person with low impulse control and suppressed hostility. And that is the person who will act out in psychological terms, sorry, that will express that violence in the workplace. Most of us realize that there are new rules in the workplace and that we have to be a little more constrained in letting our thoughts go wild. You have to be more disciplined in the workplace.

So, the people that can’t do that, there’s a psychological makeup, and we are studying it, but it has a lot to do with low impulse control and suppressed hostility. So those are two constructs that are going to play a key role in our evaluation of this. But our research on using certain kinds of assessments where you, they’re behaviorally based. What have you done in the past that would not reflect and resonate with this work environment? And really, you just want to fine-tune that, but that’s for the employees, the guests, and the patients. So that’s a whole new challenge, and we’re trying to tie work that we’re doing with facial recognition so we can quickly get a handle on who’s coming into our safe zone.

Dr. Charles Denham:  Well, thank you, David, and we look forward to future time with you as we dig into the solutions. We really appreciate it. 

David Morris:  Yeah, so it’s always an honor to speak with you, and I appreciate the opportunity to talk with you about this very important problem that’s emerging. We’re becoming better at defining it, and once we’ve got it defined, we will be able to address it much more effectively. But thank you again. I look forward to working with you in the future.

Dr. Charles Denham:  So, we are very, very pleased to have David helping us with this area. And those of you that are on the podcast, you can actually follow the slides along with the video. It’s now a great pleasure to introduce Dr Casey Clements. He has been with us with our program over a number of years. And he really was our go-to leader in sepsis. However, he has great passion and has expanded his expertise in several areas. He is a consulting physician and assistant professor of emergency medicine at Mayo and Rochester –  Mayo Clinic in Rochester. He’s currently the clinical practice chair, focusing on a large-scale interdepartmental and interdisciplinary practice improvement program. He also serves as the staff safety officer for the Mayo Clinic, leading occupational safety with a team responsible for integrated safety management and many programs that address staff safety in terms of injury prevention, mitigation, and response. And he has a great passion for healthcare-based violence mitigation and has been leading work in that area since 2014. He now chairs a complex behavior committee for Rochester and the Mayo Enterprise and spearheads violence, prevention, mitigation, and response efforts. And so, now Casey, please go ahead and share, or I can advance your slides, whichever you wish.

Dr. Casey Clements:  I’ll go ahead and do it. I put lots of little clicks in there, and I’ll drive you nuts asking to advance if that’s all right. And I’ve got it already here for you. So it’s kind of a strange title. I had the luxury of being able to hear what Vicki had said and what Greg had said before I put this together. And so it’s nice to be able to show up in person, because you can highlight the things that you think maybe deserve a little extra attention. And as a recovering researcher, I’m also very data-driven. And so, I put some data around some of these things that we’ve been covering at a high level because we’re quality people on this webinar, and we like to act on metrics and measurement.

And I’m going to talk a little bit about that because workplace violence is a hard thing to grasp. So really, what I’m going to talk about is not just what we do know, but many things that we need to know, but we need to find out if we’re going to make some headway in this space. So first of all, I want to highlight one of the things that our speaker said that is the most important thing. And I don’t have a tattoo. My wife would kill me if I got a tattoo, but if I were to get a tattoo, this is what it would say. It’s not part of anyone’s job, especially a healthcare worker who’s chosen to help people, to be assaulted, abused, harassed, or threatened, right? This is that expanded definition of the joint commission that we were talking about. And it is not part of the job. And, the second thing I want to highlight is what we just heard from our colleague that we are reporting is a violence issue, and it’s more than just a little issue. I’ll show some primary data in a little while, but I will tell you that your healthcare institution is in the same realm. There are not people who are doing really well at this, in this space. So when you hear some of the staggering numbers of violence events that are happening in hospitals and clinics across the country, I think it’s fairly safe to say that you can multiply that by four for physical acts of violence, and you can probably multiply it by a much larger number for these abuse harassments and threats that people are dealing with on a frequent basis. There are pockets of our practice that we have no idea what’s going on because it’s never been part of the culture to report these things.

When you think about places like appointment lines, this is how people are getting access to medical care. And when they don’t get an appointment in the timeframe they want, or with the person they want, or in the way that they think it should be arranged, it is extremely common for those people to be horrifically abused on a daily basis. And I only know that because we reach out and ask them at different organizations. Because if you look at your reporting that’s happening, none of that is often ending up at all in our workplace violence reports. The other thing that I want to point out is that nursing has done a really good job at getting ahead of this. A lot of the best evidence that we have around workplace violence is from groups like the Emergency Nursing Association who have studied this longitudinally for some time.

And indeed, nurses are generally the most affected by workplace violence in healthcare. And you can imagine why.  They’re the ones who spend the most time with the patient. They’re at the bedside. They’re the ones who are having to adjust people’s bodies when they maybe don’t want to be adjusted. But nursing has gotten out in front of this and has been, thankfully the canary in the coal mine to tell us that we have a problem. But we’ve started to look at other places within our practice to see who else is affected by violence. And once we started turning over some of these rocks, it was pretty impressive to find where we didn’t know what we didn’t know before this. Now, certainly survey-based data is prone to some error, like bias recall and selection bias for who’s going to participate in these studies. Still, it really is the best that we have for a lot of things in workplace violence because it is an experience that’s not always objectively measurable.

And so this is from one of our publications at Mayo that looked at different disciplines working in the emergency department, where we really reached out to all of them holistically and said, what have you experienced? Not just have you experienced violence, but trying to define that a little bit. And on the left, you can see that we’re talking about verbal threats, verbal abuse, harassment, and whether or not people reported that among different disciplines. And on the right, you can see the acts of physical violence and assault. And so, one of the things that you’ll immediately see is that there is no group, none whatsoever, that has not experienced a significant amount of verbal abuse, harassment or threats. And when you look at that, did they report it or not? It’s relatively atrocious now. Security personnel are the most reliable reporters.

And that’s been true, I think, in a lot of different studies that have been published. It’s a part of their culture and it’s a part of their job expectation that they’re going to be reporting these things. The bedside clinicians and care teams are not as good at this, particularly related to verbal problems. We’re talking less than 15% for almost every group. When we get to physical violence, that reporting gets a little bit better, but not much. And some of the folks that really don’t report this, you’d be surprised. They’re physicians, they’re clinicians. And there’s, there are some other groups. There are groups that are at risk for workplace violence in our healthcare settings based on their job. And I would point out radiology technicians, they’re often doing painful things, having to get x-rays. They’re locked alone in a room with the patient.

And patients will hit and kick them. And so, as we consider who’s at risk for violence, I think it’s important to point this out. I will also point out that where this violence happens, similar to the fact that nurses have done a great job at ringing out the warning bell, this does not just happen in emergency departments. Here at Mayo in Rochester, 89% of our assaults in the last calendar year took place not in the emergency department. And those were the ones that were reported. When we talk about what’s actually a contributing factor to causing people to be violent in healthcare, I really think this is the next wave of what we need to figure out. We don’t know why people do what they do, but we have some biases that we need to be extremely careful of.

And there’s some that I’ve heard of even brought up on this webinar. I will say this in no uncertain terms: outside of chemical substance abuse, mental illness as a treatable access-one disorder is not associated with violence. And I think that we need to be very careful, you know, when big, bad, ugly things happen – when mass shootings happen, when we have things like we heard about last week, our immediate response a lot of the time is, well, that person must be mentally ill. And that is a disservice to people with mental illness, which is over 10% of us all the time. And it’s also a disservice to understanding where we can intervene when we talk about things like access to mental healthcare that doesn’t really get to the root of violence. That said, chemical health does.

And drugs, drug abuse, and alcohol abuse definitely contribute. I like to tell this story. You know, schizophrenia is 1% of the world’s population everywhere. It doesn’t differ based on society, country, or the other or the like. And outside of drug abuse, is not really associated with violence. But we can see a clear association of violence when folks with schizophrenia self-medicate with some drug abuse. So I want to point out here that this is an emergency nursing association article from many years ago that mental health issues only contributed about 5% of the time to violence in and outside of the emergency department, less than 3% of the time. I will actually give our data here as well. So at Mayo in the last calendar year, only 3% of our physical assaults actually happened in the mental health unit.

It’s far more dangerous from a violence perspective to be on a med surge floor in our hospitals in the United States than it is to be in a mental health treatment unit. I would also point out the things at the top of the list that are contributing. And as I said, drugs, as drug-seeking behavior. Patients under the influence or on withdrawal from substances are really up there. Dementia absolutely plays into this and more so on the inpatient side than on the emergency department side. But it is, it is also a key contributing factor.

And the second thing I want to point out, and this is more to highlight what other folks have said, is that we talk about workplace violence prevention, and that is the pipe drain. That’s where we want to all get. But how to prevent things is really, really difficult when we don’t understand why there’s something different fundamentally about how people in the public patients and visitors interact with healthcare providers as compared to everybody else in their lives and other aspects of the economy, that they’re more likely to hit, kick and threaten us than they are other folks. And so, while we are working to prevent that, part of that is prediction. Part of that is setting up systems that make it more difficult to harm also; however, we have to be able to mitigate the things that are happening. And Vicki talked about that some – and respond when bad things do happen.

And that’s actually harder than it sounds. You might think, oh, well, we need to go and support them, provide them care that they need and, and, you know, pat them on the back. It’s far more complex than that, mainly when crimes are involved. And as an institution, we need to ensure that we’re supporting people at every level in the ways that they need to, not just internally to our healthcare organizations but externally as well. You know, Vicki talked a little bit about how to build a workplace violence team. I’ve done this a couple of times and I’ve done it well, and I’ve done it not so well. I think one of the things that you can’t really do is, you can’t really give an all call and say, everybody who’s interested in helping with workplace violence, please come to this meeting room on the third floor at two o’clock on Thursday.  I’ve done that. And who showed up was every single nurse manager from every single unit in the hospital, because people are very, very passionate about this. So there’s not a lack of willingness to help that you’re going to find as you build your teams. What we really need to do is we need to target expertise based on both roles and in the knowledge and skills that they bring. At Mayo Clinic, we’re firm believers in a triad leadership model where there is a physician, and nurse, and an administrative partner. I will advocate and say, that works well. The other thing is that there really needs to be bedside leadership. You know Chief Adcox and Vicki, they do a fantastic job. So does Matt Horace here and our security team at Mayo Clinic. And, they can help with responding when things happen with posting personnel, taking all the information that we can with alarms, cameras, and many different tools. But one of the things that they may not understand in the same way that a nurse or colleague of a nurse who just got hit by a patient, needs to walk back into that room in a few hours and take that same patient’s vital signs again. And so when there really needs to be leadership from the bedside, and there needs to be, the clinical practice needs to be involved in mitigation efforts for them to be truly successful, in my mind. I’m sure we can talk about that after I’m done with these slides, but I, I think this is actually key to moving things forward. 

And thirdly, we can’t really shove workplace violence within an organizational structure where it’s separated several steps from the bedside to leadership, and then several steps when something needs to be done as far as an actionable item back up to the group that is empowered to make a change. And I call that, you know, one step from the bedside to the boardroom. So you have bedside representation on leadership groups. And that leadership group is both empowered, has designated authority, or is very close to a group that has designated authority to make changes for policy, procedure and guidelines or, or to really move the needle on this. So I do wanna talk a little bit about the outcomes of workplace violence. I hope that we’ve convinced you over the course of the last hour that this is a huge deal. Everybody said that Chuck asked everybody the question, is workplace violence a big deal? Yes. but it has some extremely significant outcomes, which I think are guiding the future of healthcare in our country. And this is hot off the presses. This is my colleague Dr. Serena McGuire and myself and colleagues studying at a Midwest-wide health system for a number of different hospital services that touched the emergency department and how they may have been affected by violence.

And, I want to point out that in general, people still feel that they stay safe, that they feel safe when they’re at work. Not everybody, but, the feeling of safety is not the biggest deal, I think when it comes to violence. And if you’re just measuring how people feel at work, I think you’ll miss the boat a little bit of the time. But I will point you to the second half of this down here, that about half of our people in every discipline in healthcare have fundamentally changed the way that they interact with or perceive patients based on their experiences with violence. That is an astronomical change in healthcare. And, they go on to say that actually about one in five healthcare workers have had symptoms that we would contribute to post-traumatic stress after their violent events.

And a full 18.5% of people have considered leaving either their position or the profession of healthcare because the violence that they’ve been experiencing. And with the staffing crisis that we have around nursing and other roles in our healthcare systems, we cannot afford to have almost a fifth of our workforce considering leaving because of workplace violence. I do want to just point out one additional thing before wrapping up here, which is we need to keep people out of hospitals who don’t have a medical or psychiatric reason to be in hospitals. And I know that there is a lack of resources around the country for people to have safe places to go. We don’t want to criminalize people unless they’ve committed crimes. We don’t want to take people out of their homes or the like, but sometimes there’s not another safe place to go.

And as community policing models shift towards mental health intervention, some of the legal system shifts towards stays of commitment or revocations thereof, and where do we house committed patients not wanting to have done that in jail. There’s not really a designated place or an output disposition from these questions. And they end up sitting in emergency depots, emergency departments, and hospital wards, for sometimes up to a year before they are. There’s other places that can be found to house these folks with difficult-to-control behaviors. So while, you know, we talk about violence in healthcare, it’s compounded when it’s violence because of behaviors for people that don’t even have medical or psychiatric reasons to be in the hospital. And that is not an insignificant number of people in our country. And I, I just want to bring that up as, as a confounding factor.

As I said, we don’t look just inward to our hospitals for how to do this. Vicki mentioned this a little bit about the chief of police and, potentially the county attorney or the city attorney there in Houston. We identified a number of years ago, that we tend to be insular in healthcare. What can we change in the hospital? What do we have power over is one thing? But we exist as part of a public safety net, and in the public sector that we interact with, many different organizations who bring people to us for help whom we support in their work, and also whom we know disposition to, or we get people out to. So we don’t exist in a vacuum and we really need to work closely together. So here we built a community collaborative. This is about six or seven years old now, and I sit down quarterly with a number of different leaders from that hospital and healthcare organizations. So you can see a ton of people from around the community who we interact with and need to coordinate with really well. And that is the police chief and the sheriff. And previously, the juvenile detention centers. It’s the community response case, social workers, community behavioral health hospitals or community psychiatric hospitals, detox, and our EMS services. And I encourage this as a best practice that if your hospital, if your community doesn’t have something like this, it will make it better for your community for this to exist and to work together in a productive way. And with that, I can stop sharing. Chuck, I can pass it back over to you. Like I said, I like the opportunity to go at the end and highlight the things I wanted to. I hope I didn’t throw any wrenches in what you wanted to do. 

Dr. Charles Denham:  Thank you so much, Casey, this was just a terrific, terrific job. Thank you for building on what Vicki said. And boy, the new information is really, really interesting. 

I’d, I’d like to open it up now for the rest of the session. I just have a couple minutes – I’ll show at the end regarding misinformation, mal information, and disinformation because I think a lot of the, there’s much muddy water that we always have to kind of sort our way through. But Chief Bill Adcox is Vice President at the University of Texas MD Anderson Cancer Center. He’s the Chief of Police. Most importantly, I think he has just been our partner since 2015 on our Med Tac program when we got started. And Casey, you’ve been such a great supporter, as well as Randy Styner, who I’ll introduce in a moment.

Chief Adcox really is kind of a pathfinder in threat safety science. And we’ll have an upcoming book that a number of us are contributing to in that area. Chief, you were a terrific mentor to Vicki.  You did a terrific job of really helping us keep focused on these 30 merging threats. And I’ll also introduce Randy Steiner and have both of you first Chief and then Randy.  Randy is the Director of Emergency Response at the University of California Irvine. And Casey we’re so delighted to have UCI now adopting our Med Tac program, and he’s also a local expert helping us with one of our entire school districts to help reduce preventable harm prior to EMS arriving and you as professionals in emergency medicine. So, it’s a delight to have both of you gentlemen. Chief, lead off, and then Randy, and then we’ll have a round table discussion till we wrap up.

Chief Bill Adcox:  Well, thank you very much. And what a wonderful presentation. And as always, Dr. Clements, thank you so much for leading in this area. It’s interesting because there are many things in which you talk about, and it has to be multi-disciplinary. It has to be cross-functional. It has to be very close to the executive leadership in order to have success. And, you know, although Vicki points out that by the new standards, there has to be a person appointed. I’m not the face of the workplace violence program. Our program is absolutely clinician faced. We actually have a director for workplace violence who is a clinician for many years, as a clinician in this area. So we work with everybody across the board to do everything we can. But I will tell you that you, one of the big points that really resonates. I hope everybody takes this to heart, if you have let’s say less than 80% of reporting right now, I think the stats were like 19 ½ or 20% of the people are actually reporting workplace violence.

That’s the, the old rules. If you look at the new definition, I would suspect that that reporting is far worse. So if we don’t even know what’s going on, we don’t know the scope, we don’t know the depth, we don’t have a clear understanding, it’s really hard to deal with it. So the first and foremost, we’ve got to  get a good handle on what is really going on so that we can come together as a collaborative, just like Dr. Clements mentions to come together as a collaborative and come up with solutions. And that’s a very far end of that solution is anything it has to do with law enforcement, policing and all that. I have to tell you that we cannot arrest our way out of anything, and we should never even think of that.

That is absolutely the worst case scenario, and we should stay away from it. And we actually have a preventative model, even in our work. But we have to figure out what’s really going on. Now, I will say this, and I will caution, is that one of the pieces that will come out is that when we start to see some better reporting, when we get the better definition articulated, educated, trained into our staff and our faculty, and when people start to report, we have a better mechanism picking up. We have a better mechanism for doing quality analysis so that we can come up with viable approaches to it. We’re also going to start seeing some retaliation come around. So we’re going to have to be really cognizant of having a process, procedures in place to take care of that.

So I can’t say enough that we really have to get a handle on, on the problem in it at his core. Thank you very much, Dr. Clements, pointing out mental illness not the only contributing factor to these issues. We see that all the time in our line of work, even outside the hospital, mental illness is a tragedy. The, county jails have become defacto hospitals. What we’re seeing in our profession is people are just, you know, they pick up people that drop them off at emergency rooms, and emergency rooms are not even set up to be caring for these people. It may take three or four days or longer to get them to a bonafide psych hospital or somewhere that can treat them. It’s a horrible thing that’s going on. We do not have enough long-term or mid-term beds. So again, if we’re going to correct this whole problem, we’ve got to look at it holistically. So again,  we’ve got to get a handle on what’s going on. It’s got to be multidisciplinary, and we’ve got to, just consider everybody’s views and everybody’s ideas on this. So I’ll turn it back over to you. Dr. Denham.

Dr. Casey Clements:  Can I make one comment on that, Chuck? 

Dr. Charles Denham:  Yeah, go ahead. 

Dr. Casey Clements:  Just to point out what Chief and I are saying, the outcome of that is that for your healthcare organization, success does not look like a decrease in violent events. For the near terms, success looks like a significant increase in violent events because it means that you’re actually hearing about them. Yeah. And so the things that we have to rely on as metrics, they’re lagging metrics. They’re things like lost time at work due to assault by a person, which is an OSHA recordable event. So that’s going to be a relatively reliable success metric for at least the physical violence and the very bad physical violence. But the leading indicators for things like reported events is not a good metric for success.

Dr. Charles Denham:  Great. And so I want to go to Randy.  Randy, I just want to thank you and Chief Adcox and Dr. Clements for your great support since March of 2020 when we started to do two webinars twice a month, and we were focused on kind of being an educational source for many of our medical centers, but that led us to expand our community of practice from just medical centers to higher education. And you’re responsible not only for your medical center, but your entire University of California Irvine. And we’re so blessed to have experts like you that allowed us to expand from medical centers and academic medical centers to hire education in our universities and colleges. And love to get your perspective on what you heard today.

Randy Styner:  Well, first of all, thanks for having me here, Chuck. Dr. Clements, and Chief Adcox, you’re hitting it right on the head. I’d kind of like to shift a little bit because of, you know, obviously being in a higher ed environment and, you know, waking up to the horrible news of, Michigan State and just the continued epidemic, of gun violence. I have to say right up front, I’m a former Marine. I am an absolute champion of the Second Amendment and believe in the right for responsible citizens to be able to have weapons. But we are 47 days into 2023, and we’ve had 71 as of before this call. That number may have gone up—71 mass shootings resulting in over 200 people being injured.

And, you know, about 122 people being killed in the first 47 days of the year. You know the workplace violence as a whole isn’t necessarily a gun issue. But having free and unfettered access to weapons that can easily kill other people, for people who wish to commit these acts or are compelled for whatever reason, commit these acts is part of the problem. And the fact that our politicians in Washington are entirely not having any construction conversation on this is just; it’s a criminal act right there. It’s just crazy that we can’t find some common ground.  To start with, I understand the political divide in this country right now, and it’s pathetic when it comes to gun issues. There has to be an answer when, when Chief Adcox says, we have to work on this, you know, from all angles, that’s, we have to look at that issue.

We have to go to our politicians and say, we demand that you address this issue. And you come up with some solution, or at least start talking about, at least acknowledge that there’s an issue. You can’t sit there on one hand and say, oh, we’ve got this fentanyl epidemic stuff coming over the border. It’s killing all kinds of people, but they’re not taking action on gun issues when guns are responsible for all the deaths that we’re having in this country right now. So, yes, workplace violence is a very complex issue. And finding the roots or finding ways to prevent it is a very complex problem. But we have to start with,  can somebody get a weapon that you can just simply point at somebody and pull a trigger and kill them? You know that’s something we have to deal with.

Dr. Charles Denham:  So Randy, I’m going go to the number three slide, the three or four slides at the end to open this up for Casey and, and really ask Casey to respond to a couple of things and just congratulate him as well. And so the slides that I’m sharing with you and we have a video that you can go back and watch, and we’ll post it on this website for those that are in the podcast and those that are watching online later, but misinformation, disinformation, and mal information. And I wanna compliment Casey for really clarifying this issue regarding mental health because really a go-to comment is so frequently that it is mental health. And we’ve addressed in a short video how we’re in a public safety crisis, which Bill, I’d like to have you kind of just frame for us as well.

And a public health crisis with the education and the distress that we have. And much of it has come through the internet. The Internet is instantly searchable and permanent. And the group that have been really helping us understand misinformation, disinformation and malformation. The misinformation is false, but not intended to harm where people are just sending false information and just replicating it there and amplifying it on the internet. The malformation is the intent to harm, but it might be accurate information, leaking to people you know leading to harm of individuals. And then the really powerful one is the disinformation, false context, false information that is really intended for some kind of an agenda, whatever that agenda might be. It might be to get reelected as a politician, it might be any of these issues.

But we are addressing this head on, and I’ll tell you why. We put together a team of students to focus on vaccination to address vaccination hesitancy, those in the middle. And we had to pull the plug on it because we have a lot of pre-med students and students in college. And when almost 30 public health individuals who were really the best people in public health, left the profession because of the attacks that were made on them, we had to pull the plug on it because we didn’t want pre-med students who were donating their time then be barred from medical school because someone trolled them and put their name out on the internet. So, I just want to thank you, Casey, for really addressing head on this mental health issue, which is an easy throwdown, the moment that we talk about active shooter events or we talk about workplace violence. And so I want to commend you, Casey and then really open the door if you want to comment on some of the leading edge innovation you all are doing in we in identifying weapons and that kind of thing, if you’d like to do that. And then go back to Chief, and then back to Randy.

Dr. Casey Clements:  Sure. So there’s a couple things there. One is to follow up on your mental illness. There’s a couple of questions in the queue and as well about that, that I think we should address. Treatable access one, psychiatric disorders are not the same thing as behavioral health. And I see that question there. Behavioral health is when someone is brought in because of their behaviors, and people can have behaviors for a number of different reasons, including personality disorders, which are in access to diagnoses that are not easily treatable in the same way. And then chemical health issues as well, which are access one disorders that are treated separately than that. But when we talk about things like mood disorders, psychosis or mania, some of those things are associated with difficult to control behaviors, but they’re not associated with violence in the same way.

That follow-up question on that, I did see someone had also written there. Is the mental health number skewed because they’re trained at de-escalation maybe? I think that our training is woefully lacking in this area, in all disciplines in healthcare, and is hopefully going to be getting a lot better based on the new joint commission standards. But I, I do think that we should acknowledge that that is a possibility. But even in the public, I will say that the mental illness is not really the cause of the violence in the same way. 

The second question was about weapons detection. Randy, I agree with you a hundred percent. We have been a weapons free campus here forever, but we started enforcing that in 2022 with passive weapons to technology because we know that simple magnetometers and metal detectors don’t really work in healthcare.

They’re not as good. But passive weapons detection technology is relatively new. And around 2020 it started to really take off. And it has been very effective. It looks for the shapes of things, not just the metal of things. And so, it’s relatively low touch and pretty reliable to find weapons and we find a lot more weapons on people than you might expect. To talk about healthcare-based shootings and what causes those. And how they happen probably could be an entire other webinar and what to do about them. But there’s really two main categories. There’s targeted shootings. This is for when they’re after a specific person. And those generally are not coming in through your front entrance. They’re looking for propped doors there or they’re able to get in your entrance because there’s no screening technology. But they’re not coming in guns blazing from the front door. 

The second kind are folks who have a very stressful situation and they’re going to yell at you. They might swing at you, they might hit at you. And if they have a gun at hand, that turns into a whole different realm of deadly. And that’s really where a lot of healthcare-based shootings happen as well. And I can point back to the last five months. And so weapons screening at the entrance to a hospital actually is very good at preventing that. And people, in our experience, actually understand and they’re not upset about not bringing a weapon into a hospital. They’re not intending to cause harm with it when they bring it in. That intent comes later when they become distressed and have that weapon at hand. And so for that reason, I actually think that weapons detection technology on the entrance to hospitals or to healthcare institutions is very effective at preventing both kinds of healthcare-based shootings.

Dr. Charles Denham:  And Casey, you did share that you were really surprised at how many. You want to comment on that and then we’ll go to Bill and then to Randy.

Dr. Casey Clements:  Yeah, I don’t want to share specific numbers because I don’t know that it’s necessary, but there are more weapons on people in the public in our country, regardless of where you are. Because we have data from rural practices, we have data from suburban practices, we have data from smaller urban cities and there is just a lot more weapons on people in our country walking around today than I think most people know. And, and so trying to keep those out of our clinical and healing spaces is a challenge, but it is possible.

Dr. Charles Denham:  Chief, comment last, then to our Patient Advocate, and we’ll wrap up.

Chief Bill Adcox:  Thank you very much. I think you made some very good points. I, I want to go back to, we’re talking here about dispelling this, the myth about mental illness as this great contributor to violence. But we also need to talk about why we look at this disinformation, disinformation about this, how we micro this knowledge, for example, we compare ourselves to other free countries and say, well, you know, our rates are this or that. Well, quite frankly we have far more weapons in our country than most any other country, any free country period. We have far more crimes being committed than other countries because we define it differently. And so we’re not comparing apples to apples or oranges to oranges, and that is the problem. We don’t know what’s really going on in the hospitals until we can get to the bottom of workplace violence and what has contributed to it, and what the actual numbers are, we can come up with viable solutions.

And not every area is the same. Quite frankly, most murders in the United States are being committed in small geographical areas. You, you can go most anywhere in the United States, and you’d not have to deal with an area that’s having a large number of murders. But that’s not the narrative. And we need to be honest and we need to get the right data. And so each hospital is going to be a little bit different. And we’re very thankful that Mayo, for example, is leading the way in a lot of this area. And your research, Dr. Clements. And we need to drill down and find out what is the real scope, what are the real issues and what are real causations so that we can come up with viable alternatives, and viable interventions.

And everything from where we’re trying to get to prevention all the way through, what do we do to mitigate and unfortunately, we have to a very quick response to take care of secondary damage. And that is the response. And I think we can do that, but we have to be open and honest and bring our right people together. And it is not one type of professional’s responsibility. It is each and every one of us, from each type of employee, again, multidisciplinary, cross-functional. And again, I thank you very much Dr. Clements and Randy for bringing up some good points. But we’ve got to stop talking in cliches and stop talking about macro data and all this stuff. Let’s, let’s zero down and find out what the real problem is. It’s like, it’s like surgery. I would assume that you’re just not just cutting anywhere in the body, you’ve kind of zeroed down where you’ve got to go. So again, we’ve got to do that. So, I’m sorry to ramble, but…

Dr. Charles Denham:  Thank you, Bill. Really great comments. We’ll go to Randy, and I just want to tell the audience we’re returning to workplace violence and covering this broader definition in the coming months. And we welcome you to join us. 

Randy would you like to make your final comments and then we’ll go to our Patient Advocate, Voice of the Patient, and we’ll close.

Randy Styner:  Yes, sir. What a great discussion and thank you Dr. Clements and Chief Bill Adcox for those comments. And Chief, you are so right. The data is really what we have to look at and we have to drill down and we have to figure out, you know, what the root causes are. But, you know, on the bigger level, the data out there has to be presented factually. And it just, every time I hear, you know, in the political divide of one set of politicians using data to, to make one point and the other’s using it to make another point, and using data for political points versus data to solve a problem is just something that we as Americans, we have to demand better from our politicians. So, we have to, you know, however you can get in touch with them and say, you know, I don’t really care how you do it. Come together on something, find the common ground and start there as a country, we have to start there. Otherwise, this epidemic is just going to continue. People will have to have the factual information in order to get the resources, like the detection devices Dr. Clements was talking about. You know, that should be something that you can get through a grant through the federal government. You know, that the hospitals shouldn’t be having to find funding for those sort of things. We see this as a problem, it’s an epidemic. The government has to give us that acknowledgement and also those resources. And that’s why I just appeal to everybody to reach out to your representatives in Congress and, and tell them to, to pull it out and start working together so we can start fixing this.

Dr. Charles Denham:  So, and I wanna acknowledge you Randy, for your championship in the last 90 days or so to get stopped the bleed kits across the entire U C I campus, because, you know, there’s going to be prevention, but there’s also the mitigation piece. And, so we want to acknowledge you for doing that. 

So, we will now ask Jeni Dingman to close us. We always close and with The Voice of the Patient and Family and keep our compass heading straight. Jeni is a national leader in patient safety and quality. She was on one of my committees with the National Quality Forum on Safe Practices. She’s a published author and she’s a steadfast supporter of families across the country.

Jennifer Dingman:  It was really a great program today. I greatly appreciate all of our speakers, and I am thanking all of the participants in this webinar. Again, I urge you to please share the program recording with all of your friends, colleagues, family members, and anyone else that it might help. This is a very, very important subject and being able to protect yourself from workplace violence is very important. Thank you all for being here. God bless you, and we’ll see you next month.

Dr. Charles Denham:  So, we’ll close with the comments that we generally close with on our Med Tac programs. We need to fight the good fight, we need to finish the race, and we need to keep the faith. And we’re just so thankful for these terrific speakers today. And we’re going to tackle this broadened definition in the months to come so that we can really have some practical discussions regarding solutions, prevention, preparedness protection, and performance improvement. Thank you all for being with us today. And that will end our webinar, our 200th monthly webinar today. Thank you.