Category: Operational

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Workplace Violence – New Joint Commission Standards

The Joint Commission

The Joint Commission has new standards for Workplace Violence in healthcare.

 

Monica Cooke, BSN, RN, MA - ED Behavioral Health
Monica Cooke, BSN, MA, RNC, CPHQ, CPHRM, DFASHRM

We should not be surprised!

 

Effective January 1, 2022, new and revised Workplace Violence (WPV) prevention standards will apply to all Joint Commission-accredited hospitals and critical access hospitals.

“According to US Bureau of Labor Statistics data, the incidence of violence–related health care worker injuries has steadily increased for at least a decade. Incidence data reveal that in 2018 health care and social service workers were five times more likely to experience workplace violence than all other workers—comprising 73% of all nonfatal workplace injuries and illnesses requiring days away from work. However, WPV is under-reported, indicating that the actual rates may be much higher. Exposure to WPV can impair effective patient care and lead to psychological distress, job dissatisfaction, absenteeism, high turnover, and higher costs”. (TJC, 2021)

Staff in healthcare settings suffer abuse and aggression on a daily basis by patients, visitors, and other employees. Historically, healthcare staff have been led to believe that this is “part of the job” and that there was nothing that could be done to prevent these events. While these events may not be viewed as “violence” by most workers due to their current work culture; they are in fact, defined as violent acts that should not be tolerated. These violent acts should bring an immediate response by managers and other leaders. Healthcare settings may not be able to prevent all events of violence, but they can establish a culture of non-tolerance and have interventions and controls ready to implement when they occur. Over time, the use of proven, successful strategies can work to significantly reduce these occurrences.

A summary of the new standards are outlined below for quick reference.

1. Standard EC.02.01.01: The hospital manages safety and security risks.

EP 17: Conduct an annual worksite analysis related to the workplace violence prevention program and take action to mitigate/resolve safety/security risk concerns based on the findings.

This new standard requires that the organization develops a WPV prevention program. The OSHA website provides specific guidance on what such a program should include.

2. Standard EC.04.01.01: The hospital collects information to monitor conditions in the environment.

EP 1: Establish a process for continually monitoring, internally reporting, and investigating the following:

– Injuries to patients or others within the hospital’s facilities

– Occupational illnesses and staff injuries

– Incidents of damage to its property or the property of others

– Safety and security incidents involving patients, staff, or others within its facilities, including those related to workplace violence

– Hazardous materials and waste spills and exposures

– Fire safety management problems, deficiencies, and failures

– Medical or laboratory equipment management problems, failures, and use errors

– Utility systems management problems, failures, or use errors

EP 6: Report and investigate the following: Safety and security incidents involving patients, staff, or others within its facilities, including those related to workplace violence.

 

3. Standard HR.01.05.03: Staff participate in ongoing education and training.

EP 29: Provide training, education, and resources (at time of hire, annually, and whenever changes occur regarding the workplace violence prevention program) to leadership, staff, and licensed practitioners. The hospital determines what aspects of training are appropriate for individuals based on their roles and responsibilities. The training, education, and resources address prevention, recognition, response, and reporting of workplace violence as follows:

– What constitutes workplace violence

– Education on the roles and responsibilities of leadership, clinical staff, security personnel, and external law enforcement

– Training in de-escalation, nonphysical intervention skills, physical intervention techniques, and response to emergency incidents

– The reporting process for workplace violence incidents

 

4. Standard LD.03.01.01: Leaders create and maintain a culture of safety and quality throughout the hospital.

EP 9: The workplace violence prevention program is led by a designated individual and developed by a multidisciplinary team that includes the following:

– Policies and procedures to prevent and respond to workplace violence
– A process to report incidents in order to analyze incidents and trends
– A process for follow up and support to victims and witnesses affected by workplace violence, including trauma and psychological counseling, if necessary
– Reporting of workplace violence incidents to the governing body

 

Most authorities believe that healthcare lags far behind most industries in the prevention of WPV, most likely due to the compassionate nature of the business.

It is possible to be compassionate and be non-tolerant of abuse or aggression.

If there is an adequate workplace violence prevention plan in place and if staff, particularly at the caretaker level, are willing to enforce and adhere to it in order to shift the culture.

 

Click Here for our ED Workplace Violence Course!

 

 

 

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Behavioral Health (Post-Pandemic)

Behavioral Health in the Hospital Emergency Department

Behavioral Health (Post-Pandemic)

 

Monica Cooke, RN, BSN, MA - Behavioral Health

Monica Cooke, BSN, MA, RN-C, CPHQ, CPHRM, DFASHRM

TAKE-HOME:  Hospitals must be prepared for an influx of mental health patients as the Covid-19 pandemic wanes. The pandemic has led to an increase in suicide, substance use, and depression – the impact of which has yet to be fully realized. We offer insight into this issue and specific, actionable steps that healthcare organizations can take right now to help meet this challenge.

The entire population has experienced increased stress, anxiety, and worry over the past year as a result of the pandemic. In addition, many of us are struggling with severe grief from the loss of a loved one, increased depressive symptoms, and maybe even an increase in substance use. Some will recover over time without intervention, but others will inevitably spiral down. Those who might suffer from a pre-existing minor mental health or substance use disorder may become unstable and require intervention such as therapy, medication or hospitalization.

The pandemic has led to an increase in suicide, substance use, and depression throughout the world – the impact of which has yet to be fully realized in healthcare. If we believe that the “mind controls the body”, we can predict that significant numbers of persons who have acute/chronic medical or mental health conditions will require increased healthcare intervention in the not-too-distant future.

Healthcare systems must prepare for an increase in mental health presentations across the continuum of care.

What steps do we take?

  1. First, we must determine the current state of our organization’s ability to safely treat those who are suffering acute mental health conditions to include: depression, panic/anxiety, substance use, psychosis, etc.
  2. Secondly, leaders must make long overdue decisions related to allocation of human resources, environment of care design and implementing policy and practices that work to maintain patients and staff safety.
  3. Lastly, we must begin to integrate mental health care into all areas of clinical practice if we hope to improve population health in our communities.

Here are some specific ED strategies to help address the increased influx of mental health patients:

  • Designate a specific area where behavioral patients are treated in the emergency department.
  • Determine if there is a unit in the organization that can act as an overflow for behavioral patients requiring admission when there are no available beds.
  • Modify the ED environment of care to help ensure safety.
  • Identify key staff with behavioral health competencies and assign them to work with this population.
  • Adding psychiatric advance practice staff or skilled behavioral health nurses will help ensure safety.
  • Stock up on “distractions” for behavioral patients to include iPads, word games, movies, arts and craft supplies, adult coloring books, playing cards, stress balls and other stress reduction items. Offer these to patients routinely.
  • Provide frequent interaction and conduct a risk assessment of the patient hourly in the emergency department and on the medical/surgical units.
  • Modify policy to allow for the visual monitoring of more than one patient by one staff. This can be stated: “Close observation is the visual monitoring of more than one patient by a staff person for safety”.
  • Utilize family members or friends where appropriate to assist in keeping patients safe.
  • Allow time for patients to be out of their room to walk – in hallways or other safe areas.
  • Utilize and/or offer anti-anxiety or other appropriate medications regularly to maintain patient stability.

I hope that you find these strategies useful in preventing risks and liabilities in your organization.

If you have any questions, would like a free resource, or are interested in a behavioral health or workplace violence risk assessment, feel free to reach out for a phone discussion. We also offer online Continuing Educational training classes on Behavioral Health, Domestic and Workplace Violence. Nursing CE, Physician CME and ASHRM credits are available.

Please Contact Us if you have any questions.

© 2021, ED Quality Solutions, LLC, All Rights Reserved
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Informed Consent – Informed Refusal

Informed Consent - Informed Refusal

Dr. Sina Haeri - Informed ConsentBy Sina Haeri, MD, MHSA

Chief Medical Officer, Confirmed Consent

Informed Consent is an essential component of patient care, and the clinician must ensure that the decision to proceed with the proposed intervention is truly an informed one. Although this is the ideal, for most, the reality is quite different.

The process of obtaining an informed consent is often overlooked, abbreviated, or delegated to assistants. Patients instill their trust in the clinician, and expect to have information presented to them without bias, and in detail. However, the reality is that many forms are filled with complex medical jargon, and patients often are not making the decision in a neutral environment and typically lack adequate time to process the information. This process requires time, patience, and specificity.

Informed Consent in the Ideal World

The informed consent process generally follows the discussion of the diagnosis. This process, if done properly, should include the following steps:

  • Explaining the nature of the procedure in layman’s terms
  • Discussing common risks associated with the procedure
  • Reviewing benefits of the procedure, along with any potential treatment alternatives
  • Consistency in the risks and benefits discussion for each patient
  • Allowing adequate time for questions
  • Informing the patient of their legal right to refuse (informed refusal)
  • Providing a neutral environment for the decision – without coercion
  • Documenting the above process, patient understanding of the information, and agreement to proceed

Unfortunately, there are a myriad of reasons why this is not always the case.

Informed Consent in Our World

The reality that many clinicians live in, is a world where they are under pressure to see more patients in less time and continue to provide high quality care. Unrelated urgent issues may demand the clinician’s time and attention, resulting in consent not being top of mind. There are ample distractions that can influence a clinician’s mental state when consenting a patient, whether that be work or personal life. In addition, the clinician may unintentionally and/or subliminally discriminate against patients in assessing their level of understanding, affecting their care.

Sometimes, this process may be delegated to a nurse or resident, and the clinician not be present for the actual consent. Perhaps there is some form of language barrier, and then communication must go through a third party and is mistranslated or diminished. That is not to say that all of these problems plague every single clinician, or that on any given day a clinician would definitively deal with even one of these. However, trends in the industry suggest that these are very real circumstances that do affect the consent process. These situations not only make for poor consent, but also increase the potential for medical errors, unhappy patients, and ultimately litigation. If you cannot be confident that every single consent you’re doing is of the highest quality and standard, there is a problem.

Worst case scenario for the patient, in terms of consent gone wrong, is that they experience an unknown complication that wasn’t addressed during the informed consent communication process with their clinician. This means they are in pain, unhappy, and frustrated with their clinician. Indeed, one-third of the 20,000-23,000 medical malpractice lawsuits filed annually allege poor communication and failure to adequately consent. When litigation is filed against a clinician, they are impacted mentally, financially, and worse, the stress of the litigation inherently impacts the clinician’s future performance and/or reputation.

How to Improve?

Fortunately, there are many adjustments that can be made to ensure you are providing every patient with the highest quality, standardized, unbiased informed consent process. We propose that each institution, irrespective of size, consider the following steps:

  • Acknowledge that there is room for improvement in the consenting process and take the necessary steps to find the pain points in your organization that may be contributing to lower quality consenting.
  • Be open to new opportunities that can help elevate your consenting process if necessary. In a new age of technology and innovation in medicine, there is no reason you can’t extend this same level of innovation to your consenting process.
  • Leverage your invaluable feedback resource: the patients! Make sure to ask them about their informed consent.

Diligence is key in providing the best care and informed consent. Though it is easy to let drift to the back burner when there are seemingly more pressing matters, it is essential to always keep the informed consent process as a priority.

 

Sina Haeri, MD, MHSA, Chief Medical Officer, Confirmed Consent

Dr. Sina  Haeri is a Maternal-Fetal Medicine specialist with over 15-years of leadership experience in healthcare including developing maternity programs to improve access to care for some of the nation’s largest healthcare entities including HCA and Access Physicians.  He currently serves on the Society for Maternal-Fetal Medicine’s Healthcare Policy and Advocacy committee. He co-founded Confirmed Consent in 2017, where he is now the Chief Medical Officer.

About Confirmed Consent

Confirmed Consent is an interactive peri-operative consent platform that provides standardized and documented patient education and facilitates obtaining informed consent while confirming the patient’s competency and cognition.

 

Final Thoughts

Robert Broida, MD, FACEP

President, ED Quality Solutions

Informed Consent is a huge issue for many healthcare systems. Usually treated as a “necessary evil,” or “useless paperwork,” consents can be your best friend or your worst enemy in the event of an adverse outcome.

In the Emergency Department (ED), we have historically focused on patients leaving before treatment was completed or against medical advice (AMA). In fact, most hospitals’ paperwork is focused on AMA.  A far more common issue is informed refusal of tests, procedures, examinations, etc. Patients have the right to be informed about their treatment options, risks and benefits (including non-treatment). With greater patient financial responsibility due to high deductibles, this takes on an ever greater place in our healthcare system.

Proper ED Informed Refusal should contain the following items:

  • Informed Refusal of tests, procedures, exam, etc.
  • Physician documentation of the patient’s decision-making capacity
  • Physician discussion of risks and benefits with the patient and documentation of that discussion, including treatment alternatives and non-treatment (ideally in the context of Shared Decision-Making)
  • Physician must offer (and document) an open invitation to return for care
  • Nursing staff documentation of the patient’s understanding of the discussion, the various treatment alternatives and their willingness to accept the risks as part of their informed refusal.

It is important that several of the items be performed directly by the physician and not delegated. Equally important is to have a system to memorialize the discussion and the information conveyed. Consistency is important. This can be with a well-constructed form or via an electronic system. Flexibility is essential in the ED, due to the wide variety of conditions treated and the unique situations we encounter on a daily basis. As a best practice, hospital nursing staff should independently document patient understanding. Such corroborating notes are invaluable should there be any future litigation.

Healthcare systems should take a careful look at their consent/refusal process. While it is tempting to endorse a “one size fits all” approach to this issue, differences in clinical process must be considered.  There MUST be a system in each department that actually works and provides the necessary protection.  Informed Consent/Refusal should be a key focus of each hospital’s Legal and Risk Management Departments.

 

Resources:

https://www.thedoctors.com/articles/informed-consent-substance-and-signature/

https://www.thedoctors.com/Articles/Informed-Refusal

https://www.medpro.com/documents/10502/2820774/Article_Informed+Refusal_A+Review.pdf

https://www.reliasmedia.com/articles/64232-informed-refusal-just-as-important-as-informed-consent

https://physicians.dukehealth.org/articles/informed-refusal-what-you-need-know

https://www.capphysicians.com/articles/informed-refusal-defense

 

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