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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

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!