Workplace Violence

Rx for Violence

As violence in health care settings increases, awareness and de-escalation training for workers can go a long way toward preventing crises.  
By: | October 15, 2015 • 12 min read

Law enforcement responded to Brigham and Women’s Hospital in Boston on Jan. 20, 2015, where a cardiologist was killed.

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Dr. Jeffrey Ho treats patients in a busy Level 1 trauma center at the Hennepin County Medical Center in Minneapolis, and he teaches emergency medicine at the University of Minnesota Medical School. He’s also a sworn deputy sheriff in neighboring Meeker County.

The combination of medical practice and law enforcement is not the contradiction it might seem.

It led to his belief that the most effective strategy for preventing violence was not necessarily more deterrence in the form of weapons and armed security, but more and better training in violence recognition and pre-emption for people who dedicate themselves to the helping professions: doctors, nurses, technicians, administrators and therapists, as well as support staff such as receptionists and maintenance crews.

Health care workers are injured through violent acts at more than four times the national rate, according to the U.S. Bureau of Labor Statistics. FBI statistics show the incidence of active shooter incidents in health care settings rose from 6.4 per year between 2000 and 2006, to 16.4 per year between 2007 and 2013.

Those numbers are a gross underestimate, Ho said, because the health care culture doesn’t yet take assaults seriously, other than the deadly ones. OSHA doesn’t break out violence in its statistics on injuries to workers, although it breaks out other sources of injury. And workers themselves don’t consider minor incidents worth reporting.

When he consults with other hospitals on beefing up security — another of his jobs, along with his role as medical director for TASER International — Ho asks caregivers, “Has a patient ever threatened you or has anybody ever touched you?”

“Every hand goes up,” he said. Then he asks how many times they’ve reported it. “Nobody raises a hand,” he said.

A Big Problem, But How Big?

When an accurate registry of incidents exposes the pervasiveness and severity of the problem, Ho said, hospital administrations, the insurance industry, the government and general public will be shocked into corrective action.

Dr. Jeffrey Ho, Hennepin County Medical Center

Dr. Jeffrey Ho, Hennepin County Medical Center

However, obstacles to accurate reporting are nearly as pervasive as the violence itself.

The main reason violent incidents are under-reported, said Barry Weiner, managing director, health care practice leader, Aon, is that there is no mandate for facilities to report all events.

For those that report anyway, there is no universal definition of a reportable (or recordable) injury, said Jane Lipscomb, professor at the University of Maryland Schools of Nursing and Medicine, and author of “Not Part of the Job: How to Take a Stand Against Violence in the Work Setting.”

OSHA has one set of requirements, workers’ compensation carriers may have another and facilities may have their own.

“What’s an ‘event’?” asked Weiner. “Every emergency department sees a half-dozen on a good night, but won’t report all of them. Where is the threshold for reportable incidents?”

“We had to get staff to understand that behaviors that would be criminal in other settings are not OK just because they happen in a hospital.” — Dr. Jeffrey Ho, Hennepin County Medical Center

Many victims, particularly nurses, don’t report staff-on-staff incidents for fear of retaliation, said Lori Severson, health care loss control consultant, Lockton Cos.

An Institute for Safe Medication Practices study finds a virtual epidemic of violence, intimidation and passive aggression by health care workers, who may be stressed out by accountability for life-and-death procedures.

A dysfunctional team, said Lipscomb, is more apt to make errors, which may expose the organization to litigation. “Increasingly, organizations recognize that staff safety and patient safety are closely linked.”

Obstacles to Reporting

Electronic medical records, mandated by the Affordable Care Act for patient records, may contribute to the problem, said Weiner, as hospitals may have a disincentive to record incidents.

“Discoverability can be an issue,” he said. “An electronic record is permanent and discoverable. Both sides can use it in a courtroom.”

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Not infrequently, Severson said, a repeat offender cycles through a facility again and again. “Health care workers may then feel workplace violence reporting isn’t a solution but an empty motion. Why report the same person multiple times?” she asked.

Veterans Affairs facilities electronically flag the file of patients who have acted out violently against staff in the past two years, and security personnel escort them whenever they’re in a facility for treatment, according to published reports.

The financial ramifications of violence combined with the need to protect employees create an urgent problem. A broker’s role, said Weiner, is to work with clients to scope out the problem.

“Some of the solution lives with us. We deliver training, promote best practices and engage leadership in meaningful discussion about reducing violence.”

Responsibility for the so-far nonexistent registry of assaults, Ho said, doesn’t belong with a government agency, but with a professional risk association.

The American Society for Healthcare Risk Management was unavailable for comment.

But a professional association faces the same obstacles as OSHA, the Department of Labor, the Crime Victimization Survey and the “other organizations out there trying to make good estimates,” said Lipscomb. “Staff don’t report if they work in an environment where they think violence is part of their job, where reporting is risky, and where it won’t produce results anyway.”

Disrupting the vicious cycle of under-reporting and perpetuation of violence, Lipscomb said, usually depends on a facility’s enlightened leadership, without whose commitment of time, resources and adequate staffing to meet patients’ needs, culture change is “nearly impossible.”

The organizations she visited to identify best practices, she said, have many things in common, such as morning huddles every day, when CEOs and unit heads get together to talk about what happened in last 24 hours. “They ask, ‘What do we need to do to make sure it doesn’t happen again?’ ”

“Staff don’t report if they work in an environment where they think violence is part of their job, where reporting is risky, and where it won’t produce results anyway.” — Jane Lipscomb, professor, University of Maryland Schools of Nursing and Medicine

This is already common practice with patient care. Taking their cue from aviation and other safety-essential industries, they have adopted a culture where errors and near misses are considered opportunities to improve the facility’s practice.

“That’s how you get people to report,” Lipscomb said. “Then you can do something about the problem.”

Changing Behaviors

Ho’s facility has done “a good job” controlling violence, thanks to senior management’s follow-up on recommendations from a violence prevention task force formed in 2007. The task force’s recommendations start with a carrot (de-escalation) and end with a stick (force). The longest journey, he said, was training staff members to consider their own safety.

Having been taught for years that verbal abuse and getting punched in the face by a distraught patient or family member is simply an occupational hazard, the forgivable by-product of grief or pain, “we had to get staff to understand that behaviors that would be criminal in other settings are not OK just because they happen in a hospital.”

In fact, several states have passed legislation making any attack on a health care worker a felony. Although there is no federal standard for workplace violence protections, according to the American Nurses Association, some states require employer-run workplace violence programs. Washington is the only state to require reporting of incidents.

Among the Hennepin County Medical Center task force’s recommendations: Signage around the facility stating appropriate behavior.

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The Joint Commission, a national certifying organization, now requires its accredited hospitals to have a code of conduct that identifies appropriate behaviors and how inappropriate behavior should be managed.

Training helps staff recognize risks, such as frustration with long ER wait times, intoxication and drug-seeking behavior, according to experts.

It teaches empathetic listening, the most basic de-escalation technique, which means the distraught person has no need to act out in violent ways to be heard, said Elizabeth Moreland, senior risk engineering consultant, Zurich Insurance.

Emergency rooms and mental health settings are particularly high-risk areas, experts said, but “everyone who has patient contact should get basic crisis prevention awareness training,” said Moreland.

Some organizations, such as the Crisis Prevention Institute (CPI), provide training specific to health care facilities. Typically, a facility sends one or two staff members for training, and they return to spread the gospel.

The National Institute for Occupational Safety and Health, the Centers for Disease Control and Prevention, and some trade associations offer free programs and best practices to help manage health care violence.

Training typically includes rehearsing non-judgmental and non-provocative responses to a distraught person’s demands. Body language can also diffuse emotions, Moreland said. For example, standing to a person’s side is a less confrontational posture than standing nose to nose.

For most people, these techniques require practice, she said. “In-service role-playing is very effective. Don’t depend on once-a-year training sessions.”

People, Not Livestock

Batsheva Katz, vice president of Windsor Healthcare Communities, which runs elder care, skilled nursing and rehabilitation facilities in New Jersey, takes pains to provide “a happy environment” as the most effective prevention against violence.

Biting, hitting, pushing and scratching are typical assaults in residential facilities, where emotions run high among residents and their families as they face the fear of mortality and the discomforts and humiliations of aging.

“Happiness” in those circumstances is a systematic, top-down effort to treat residents “as someone’s mother or father,” rather than as bodies that need to be fed and washed, Katz said.

“That means talking to them if they want to talk, addressing them by name, knowing their tastes and preferences.” It also means teaching care partners to approach residents slowly and speak softly but audibly. Care partners explain what they’re doing, such as, “I’m going to put your socks on now.”

This is a human resources issue, Katz said, requiring adequate staff, time, training and a concerted search for applicants with the friendly, caring personalities that are crucial, but harder to find than résumés boasting relevant but teachable skills.

The practice pays off in “extremely favorable” workers’ compensation premiums, virtually no claims related to violence and very high employee retention, said Ettie Schoor, president, Prism Consultants, Windsor’s hands-on insurance broker.

When new residents are admitted, Windsor’s interdisciplinary care partners and administration undertake a “72-hour meeting” with them and their families to get to know the resident’s tastes, personality, triggers and risk factors, such as dementia or a tendency to wander; if residents wander, their care partners wander with them and bring them back gently, Katz said, to avoid power struggles. Windsor matches residents with care partners they like and trust.

For example, said Katz, staff members noticed one resident’s combativeness eased on weekends, when he had a male certified nursing assistant (CNA). “All he wanted was a male CNA,” said Schoor.

Kendra L. Stea, director of client services, CPI, urges facilities to reconsider inflexible rules, policies and protocols that produce power struggles between patients and staff, which can escalate into violence.

A psychiatric patient’s request for a glass of milk at night led to “a really ugly outcome,” she wrote in a CPI blog, when a caregiver refused, saying it would lead to a stampede of midnight demands for milk.

“We have to be creative and flexible in deciding which of our rules are negotiable, and which are non-negotiable,” she wrote.

Securing the Plant

Ryan Clarke, director of security and transport, Renown Regional Medical Center in Reno, Nev., agreed that education and awareness are the best tools against violence.

After a shooter killed a doctor and wounded two others before killing himself in 2013 at the center, Clarke’s facility introduced more comprehensive staff-wide de-escalation training for handling people who are verbally or physically out of control. And it added armed security guards to its team, mostly as a deterrent to future attacks but also to add a greater level of response.

Much of its re-evaluation of the physical plant’s security addressed access control: Who needs to be where? Who’s coming into the ER? Armed security guards and volunteers, who are trained to perform a visual risk evaluation, greet people as they pass through a door.

“We put access control at main and intermediate doors inside the ER so if we need to lock down an area, we can,” Clarke said.

“If we suspect a visitor problem, we can lock the lobby off from the patient area until we can ensure that it’s safe.”

Clarke looks at furniture. Can it be broken up and weaponized? He also looks at layout. Is there enough space to separate people with a history of hostilities, maybe gang members or fighting domestic partners, who may meet again in the ER?

“In a good layout,” he said, “visitors see a staff member or security officer as soon as they enter. In a poor layout, the entrance is isolated, and nobody is there to identify potential threats.”

Some experts challenge the efficacy of color-coded alert systems — such as Code Gray for personal threat — as unintelligible and unhelpful to non-staff. Emergency codes are not standardized by any state or agency.

After the tragic 2015 shooting at Brigham and Women’s Hospital (BWH) in Boston that left a cardiologist and the shooter dead, police were on the scene within seconds, the 5 million-square-foot facility was cleared within 16 minutes and the violence was contained to the exam room.

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That faint silver lining was due, in part, to a 39-word plain-English scripted announcement that identified and located the incident and explained what to do.

An announcement “needs to be plain English so untrained visitors, patients, anybody who is in the building, can hear it and know what’s happening,” Robert Chicarello, director of security at BWH, told “Boston Magazine.”

Pamela Popp, executive vice president and chief risk officer, Western Litigation, recommended that health care facilities cultivate relationships with law enforcement.

Facilities that can’t hire security staff may offer free food or cafeteria discounts to local police, whose presence serves as a visual deterrent.

Ho agreed, with qualifications. Does the cop understand how to work in health care settings? In case there’s a pursuit inside the hospital, is the sterilization area locked? Are there flammable gasses?

“A firearm or Taser is dangerous in those environments,” he said.

A security solution that’s appropriate for one facility won’t necessarily work in another because of endless variables: differences in the community, the layout, the size of the hospital and risk factors in the community.

Study and adapt best practices, advised Clarke.

Susannah Levine writes about health care, education and technology. She can be reached at [email protected]

More from Risk & Insurance

More from Risk & Insurance

Black Swan: Cloud Attack

Breaking Clouds

A combination of physical and cyber attacks on multiple data centers for cloud service providers causes economic havoc. Even the most well-prepared companies are thrown into paralyzing coverage confusion.
By: | July 27, 2017 • 10 min read

Scenario

By month 16 of the new presidential administration, the Sunshine Brigade is more than ready to act.

Stoked by their anger over rampant economic inequality, the mostly college-educated group of what might best be called upper-middle-class anarchists — many of them from California, Oregon and Washington State — put in motion the gears of a plan more than two years in the making.

Their logic, to them at least, is unimpeachable. Continued consolidation of economic power into the hands of fewer and fewer corporations is creating a world where the rich increasingly exploit and shut out the poor.

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The rise of the techno giants is accelerating this trend, according to the Sunshine Brigade’s de facto leader Emily Brookes, an All-American rugby player and a graduate of Reed College in Oregon.

With a new presidential administration seemingly bent on increasing the economic advantages of the rich with no end in sight, nothing to do then but break things up; and in so doing break the hold of this technology oligarchy.

As Emily Brookes so forcefully put in her instant messages to the other members of the brigade: Break the Cloud.

With more than 500 members, many of them with ample financial and technical resources, the Sunshine Brigade is very capable of delivering on its plan for a two-pronged attack.

It is also radicalized enough to justify the loss of some human life, even its own countrymen, to “save” — in its collective logic — the tens of millions of global citizens that are living as virtual slaves in this callous, exploitative global economy.

With websites and digitally connected services large and small down for days, irritation turns to fear.

The first wave in the attack is an attempt to infect and shut down the data centers for the top three cloud service providers. It takes months to set up this offensive.

Rather than rely on a phishing scam from outside the firewalls of the service providers, The Sunshine Brigade uses its social and business connections to place three members on each of the cloud provider’s payrolls. An infected link from someone you know, someone in the cubicle right next to you, seems like an unstoppable play.

It only partially works. Only one of the cloud service providers is harmed when an unsuspecting employee clicks on a link from their traitorous co-worker. The released malware manages to cripple a major cloud service provider for 12 hours.

With millions of users affected, the act creates substantial disruption and garners global headlines. Insured losses are around $1.5 billion. But this is just the beginning.

The morning after, the Sunshine Brigade unleashes a far more devastating and far more ruthless Round Two.

Using self-driving trucks, the Sunshine Brigade smashes into five data centers; three on the West Coast, and two in the Midwest. Fourteen employees of those cloud servers are killed and another 23 injured; some of them critically.

This time the Brigade gets what it wanted. The physical damage to the data centers is substantial enough that it significantly affects three of the top four cloud service providers for five days.

With websites and digitally connected services large and small down for days, irritation turns to fear.

Small and mid-sized banks, which host their applications on clouds, are shut down. Small business owners and consumer banking customers immediately feel the brunt. Retailers that depend on clouds to host their inventory and transaction information are also hit hard.

But really, the blow falls everywhere.

In the U.S., transportation, financial, health, government and other crucial services grind to a halt in many cases.

Not everyone is disrupted. Some of the larger corporations are sophisticated enough in their risk management, those that used back-up clouds and had steadfast business resiliency plans suffer minimal disruption.

Many small to mid-size companies, though, cannot operate. Their employees can’t get to work and when they can, they sit idly in front of blank computer screens connected to useless servers.

For the man on the street, this is hell.

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Long lines blossom at the likes of gas stations, banks and grocery stores. A population already on edge from a steady diet of social media provocation becomes even more inflamed.

By nightfall of Day Five, the three major cloud service providers are recovered, and digital “normalcy” begins to creep back. But for many small and medium-sized businesses, the recovery comes way too late.

Economic losses promise to register in the tens of billions. It’s not being too imaginative to think that losses could hit the $100 billion mark.

Two multinational insurers based in the U.S., three Lloyd’s syndicates and a Bermuda insurer signal to regulators that their aggregate cyber-related losses are so great that they will most likely become insolvent.

Emily Brookes and her cohorts were willing to kill more than a dozen people to promote their worldview. In their youthful naiveté, they could not know just how much suffering they would cause.

Observations

For some commercial insurance carriers, the aggregated losses from a prolonged disruption of cloud computing services could be catastrophic, or close to it.

“It’s on a par with any earthquake or hurricane or tornado,” said Scott Stransky, an associate vice president and principal scientist with the modeling firm AIR Worldwide.

AIR modeled the insured losses for the Fortune 1,000 were Amazon’s cloud service to go down for one day. They came up with a figure of $3 billion.

Now consider that most businesses in this country are small businesses, with not nearly the risk management sophistication of the Fortune 1000. Then consider a cloud interruption of five days or more.

Mark Greisiger, president, NetDiligence

“Almost any company you talk about today would rely to some extent on the cloud, either to host their website, to do invoicing, inventory, you name it — the cloud is being used across the board,” Stransky said.

“It’s a significant issue for insurers and one we think about a lot,” said Nick Economidis, an underwriter with specialty carrier Beazley.

“Should a cloud service provider go down, everybody who is working with that cloud service provider is impacted by that,” he said.

“Now, pretty much every software maker is on the cloud,” said Mark Greisiger, president of NetDiligence.

“In the old days, someone would come in and install software on your servers and come in annually for maintenance. That’s all gone bye-bye. Everybody who makes software is forcing you onto their private cloud,” Greisiger said.

The aggregation risk for carriers is complicated by the degree of transparency they have into which insured’s applications are hosted on which cloud provider.

Now here’s the even trickier part. Clouds outsource to other clouds.

“It’s almost becoming a spider’s web of interdependencies on who has access to what in terms of upstream and downstream providers,” Greisiger said.

Determining which of their insureds is hosted on which cloud, and in turn, where that cloud is outsourcing to other clouds can be very difficult for carriers to determine.

Even if a company is careful to diversify the risks they’re taking, they might not realize that a high percentage of insureds are even with the same cloud provider. They could be hit with devastating losses across their entire portfolio of business, said an executive with BDO consulting.

AIR’s Stransky said his company launched a product in April, ARC, which stands for Analytics of Risk from Cyber, which is designed to help carriers gain that much needed transparency.

Among insureds, surviving an event of this magnitude will depend not only on the sophistication of their risk management department, but on the company’s overall ability to negotiate contracts with vendors and suppliers that will indemnify the company in the case of a cloud outage of this duration.

It will also depend on organization’s understanding that there is no off-the-shelf solution that will prevent an event like this or make a company whole after it.

Shiraz Saeed, national practice leader, cyber, Starr Companies

Experts say contracts with cloud service providers, customers and suppliers must be structured so that a company is defended should it lose cloud access for as much as five days or more.

Best practices also include modeling just what your losses would look like in this area, and vetting your full portfolio of insurance policies to understand how each would respond.

One broker said buyers can’t be blamed if the complexities of the coverage issues at stake here are initially hard to grasp.

“It’s becoming a spider’s web of interdependencies on who has access to what.” —Mark Greisiger, president, NetDiligence

“I think it’s the broker’s job to inform the client of this exposure,” said Doug Friel, a vice president with JKJ Commercial Insurance, based in Newtown, Pa.

“You may have business interruption coverage for direct physical damage to your building. But have you ever thought about your business income if your IT structure goes down?” Friel said.

He said many buyers might not realize there is a difference.

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Large businesses should have the resources to demand from their cloud service providers that they be indemnified for the entirety of a cloud failure event. There will be a fee for that, but it will be well worth paying, Friel said.

“You have to push,” Friel said. “They are going to say, ‘Here is our standard contract, sign it.’ ”

Don’t settle for that, he said, although many do in ignorance, he added.

“Where possible, we would look for clients to negotiate their contracts. These business relationships should be mutually beneficial, even if one of these events occur,” said Shiraz Saeed, national practice leader, cyber, for the Starr Companies.

It’s a partnership, he said.

“It shouldn’t be a zero sum game on either side. I think there should be an understanding of what the potential loss might be and then designing a contract around that,” he said.

While cloud service providers are known for having high grade security systems, most average organizations don’t have the means for that. But no matter what a company’s resources, the first step is modeling where your digital assets are, and what you and your customers stand to lose if you lose access to them.

“Most insureds don’t seem to understand the amount of individual loss that you could be subject to,” said Jim Evans, leader of insurance advisory services at BDO Consulting. “Usually this stuff is measured in hours,” he said. “But what if a cloud provider is out for three or four days?” he said.

“Trying to quantify what you did lose in an event is hard enough. Trying to do a modeling exercise about what you could lose? It’s something that just doesn’t get done enough,” he said.

Once you have an understanding of what you own and what you stand to lose, the next step is prioritizing the protection of the assets you have. That means drilling into your contract with your cloud service providers to get the maximum indemnification.

It also means spreading your risk so that if at all possible, not all of your assets or your customers’ assets are housed by one cloud service provider. Cloud platforms can be public, private, or a hybrid of the two.

Understanding where your assets are in that architecture is crucial. Spending the money to insure that they are protected behind a diverse menu of firewalls is highly advisable.

Navigating the different iterations of business interruption coverage in property, cyber and kidnap and ransom policies is also important.

Make sure your broker can provide clarity on the different types of coverages and tailor them to your needs, experts said.

The concept of design thinking is really what’s in play here. Organizations have to work with vendors in every aspect of their operations to design a risk management system that can sustain this kind of hit.

“Build a better mousetrap to protect yourself,” said JKJ’s Friel.

“Depending on your service, you need to have the best and the brightest designing this stuff. Spread the risk.”

“Don’t be afraid to ask for more,” he said.

Postscript

In engineering an attack on the cloud, Emily Brookes and her cohorts accomplished the opposite of what they set out to do.

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Only the largest corporations with the most sophisticated risk management programs were able to survive the attempt to break the cloud with manageable losses.

Small businesses, the true backbone of the U.S. economy, suffered terribly. Entrepreneurs who put their life’s work into their business lost it in many cases.

Those on the lowest part of the economic scale, the working poor, lost their jobs and their ability to cover their rent and grocery bills. They joined the ranks of those subsidized by the government by the millions.  The attempt to break the cloud resulted in an even more polarized society. &

Dan Reynolds is editor-in-chief of Risk & Insurance. He can be reached at [email protected]