WORKPLACE VIOLENCE

Background

Since April 2017, Environmental Health and Safety has been receiving Electronic Event Reports (EER) documenting incidences of workplace violence (WPV) at LLUH. Every report is reviewed and investigated, which may include communicating with employees and visiting the site of the incident. Severe incidents of workplace violence at our General Acute Care and Psychiatric Hospitals are reportable to Cal/OSHA under California Code of Regulations, in Cal/SHA’s Title 8.

Program Plan

Loma Linda University Health has broadcast its stand against violence with new signage (pictured at right) placed throughout our hospital campuses. Policy I-71 provides more details about LLUH’s stance on workplace violence. LLUH has created and implemented a Workplace Violence Prevention Plan to meet the regulatory requirement ant to create a safe environment for all patients, visitors, staff and students. In the summer of 2019 the newly-created Workplace Violence Specialist position was filled by Sarah Steahly.

Education

Completion of an 8-hour class titled “De-escalating Workplace Aggression” is a new requirement for all charge nurses, nurse educators and house supervisors, who have been designated as our Workplace Violence Advocates. Quarterly meetings will be held in 2020 to keep our Advocates up-to-date with new workplace violence initiatives, and will provide a forum to share best practices across LLUH. Advocates are also signed up to receive a workplace violence prevention blog called “Stand up to Violence.” Other levels of training depend on where the employees are working:  All LLUH employees receive awareness-level training through the BLUE book.  General Acute Care Hospital and Psychiatric employees receive annual training on preventing workplace violence. A total of 2,976 employees completed this 30-minute course on OWL in 2019.  747high-risk staff, which includes Security, Emergency Department, Urgent Care and Behavioral Medicine Personnel, received the 8-hour “De-escalating Workplace Aggression” course.  In-services about preventing workplace violence have been provided to specific departments upon request. These training are tailored to meet the needs of the department requesting the in-service.

Reporting

Since 2017, most employees have been able to use the Electronic Event Reporting (EER) system in Midas to report WPV incidents. In 2019, BMC employees also gained access to the reporting system in Midas. A log of incidents is maintained by EH&S, and all incidents that include the use of physical force are reported to Cal/OSHA. Any incident that results in a fatality or serious injury, or that involves the use of a firearm or other dangerous weapon, must be reported to Cal/OSHA within 24 hours of the occurrence. All other reportable incidents have 72-hour reporting timeline. In 2019 we had 328 reportable workplace violence incidents, 495 recordable incidents and an additional 151 reports that did not meet the definition of workplace violence. The graph on the previous page shows a slight decrease in Reportable incidents over the past three years, although there has been an increase in the number of Recordable incidents reported.

Code Gray Drill

In May 2019, LLUH conducted its first-ever Code Gray “Combative person(s)” Drill. It was comprised of over 70 mini drills in 67departments, with a total of over 1000 participants.

Facilitators for the Code Gray drill were chosen by each department. Facilitators received a one-hour training and a Code Gray Facilitator Guidebook, designed to guide the Facilitator through the Drill and to provide instructions for department readiness in the event of the emergence of a combative person. The drill was designed to be adapted to any department within the organization.

Drills are intended to serve the purpose of revealing opportunities for improvements in our processes, and lessons learned from the Code Gray Drill provided information for updates of both the institution’s Code Gray Protocol and the Facilitator guidebook, with the goal of ensuring staff safety and an appropriate response to incidents involving combative persons.

Revised Code Gray Protocol

The Code Gray Protocol was updated and the acronym S.A.N.D. was created:  Safety First  Assemble Team  Notify Security  De-escalate

GOALS

Continue work towards implementing a behavioral assessment and a flagging tool for electronic medical records

Increase compliance with WPV education

Sarah Steahly and Cambria Boyer conduct Code Gray Facilitatory Training at Quarterly Safety Coordinator Luncheon

Code Gray mini-drill, Emergency Department, office setting