Acknowledgements Molly Amman, JD Kim Anderson-Drevs, PhD, RN - PDF document

7/28/2016 Keeping Our Workers Safe: Developing a Comprehensive Program for Prevention and Management of Violence in the Workplace Lynn M. Van Male, PhD Director, Veterans Health Administration (VHA) Workplace Violence Prevention Program VHA Office of Patient Care Services, Occupational Health (10P4Z) Washington DC August 2016 Acknowledgements • Molly Amman, JD • Kim Anderson-Drevs, PhD, RN • Frederick Calhoun • David J. Drummond, PhD • Eric Elbogen, PhD, ABPP • Stephen Hart, PhD • Shawn Loftus • J. Reid Meloy, PhD, ABPP • Lt. David Okada • Gregory Roth • Mario Scalora, PhD • John van Dreal, MA • Stephen Weston, JD • Stephen White, PhD • Ronald Wyatt, MD, MHA, DMS (HON) 1

7/28/2016 To Veterans of ALL Conflicts and to Those Who Serve Them: THANK YOU FOR YOUR SERVICE 2 Educational Objectives 1. Discuss the incidence of workplace violence in health care settings 2. Identify the common safety/security issues that arise in the population of your community that may contribute to incidents of workplace violence 3. Describe the five components of a systematic facility approach to reducing the risk of violence in the workplace 4. Explore tools that can be utilized to collect data to track and predict potential disruptive behavior incidents. 5. Explain the considerations necessary in education of staff regarding workplace violence, from “see something, say something” to the assessment of educational needs by risk area, up to and including active shooter training. 3 2

7/28/2016 Agenda • Workplace Violence Prevention Program Model: Implementation Essentials and Overcoming Challenges • From Bystander to Upstander: Employees Are Our Key Asset • Incident Reporting: Knowing What We Know and Finding Out What We Don’t Know • Violence Risk and Threat Assessment in Health Care: Fundamentals of Multidisciplinary Practice for Employees and Patients 4 Workplace Violence Prevention Program Model: Implementation Essentials and Overcoming Challenges August 2016 3

7/28/2016 Extent and Characteristics of Workplace Violence in Health Care • Approx. 24,000 assaults from 2010 - 2013 • Violent crime in US hospitals per 100 beds: 2.0 (2012) to 2.8 (2015) • Emergency Department Assaults: 44% aggravated, 46% other • Bureau of Labor: 50% of workplace-related assaults involve health care and/or social service workers • Female nursing staff and psychiatric assistants most frequent “experiencers” • Approx. 60% of reported threats and assaults occur between noon and midnight Wyatt, Anderson-Drevs, & Van Male (2016) International Association for Healthcare Security and Safety (IAHSS): 2016 Healthcare Crime Survey NIOSH Type 2: Customer, Client, Patient, Student, Inmate, etc. on Employee 7 4

7/28/2016 US Veterans Health Administration (VHA) US Veterans Health Administration (VHA) 150+ Medical Centers 1000+ Community Based Outpatient Clinics 300,000+ Employees 9 5

7/28/2016 US “Health Care Community Standard” vs. VHA BANNED from HEALTH CARE VHA MUST rise to a high standard of providing comprehensive workplace violence prevention programs and organizational infrastructure. “VA Response to Disruptive Behavior of Patients” 38 C.F.R. § 17.107 (2010) 10 What VHA CAN Do Keep Veterans in VHA health care: The care VHA provides can address the 6 key protective domains. Access to care is a violence risk mitigation strategy. 11 6

7/28/2016 Protective Factors and Violence in Veterans Prot otective e fa factor ors indic icat ate e healt lth h and we well-being ing in the following ing domains ains: Living ing Work rk Financ ancial ial Psychologic ological al Physic ical al Social ial Eric Elbogen, DBC Chairs Conference, January 2014 VHA WVPP Model Employee- • Employee Threat Assessment Team (ETAT) Generated • Bullying, Mobbing • Disruptive Behavior Committee (DBC) Patient-Generated • Orders of Behavioral Restriction (OBR) + Patient Record Flags (PRF) • Prevention & Management of Disruptive Behavior (PMDB) Employee Education • PMDB Trainer Recalibration Conferences • Disruptive Behavior Reporting System (DBRS) Reporting and Data • Workplace Behavioral Risk Assessment (WBRA) Environmental • Facility-Based Design • Community-Based 7

7/28/2016 • Bystander to “ Upstander ” • Education and Awareness • Skills Van Male, February 2016 • All employees • Easy and short • “Return Receipt” Van Male, February 2016 8

7/28/2016 • Multi- and Interdisciplinary • Evidence-based, Data-driven • Structured Professional Judgment Van Male, February 2016 • Collaborative with Patient • Spectrum of “Confrontation” Van Male, February 2016 9

7/28/2016 • What is the Safety/Treatment Plan? • What ACTION should staff take to stay safe? Van Male, February 2016 Van Male, February 2016 10

7/28/2016 Violence Risk and Threat Assessment in Health Care Prediction vs. Threat Assessment Threat Assessment Prediction: Yes or No Risk Protective Factors Factors 21 11

7/28/2016 Evolution of Threat Assessment Purely Clinical Approach • Intent, plan, access, identified target, imminent? • High(er) face validity • Clinicians often barely as good a chance Purely Actuarial Approach • Increased predictive validity over purely clinical • Low(er) face validity • Does not inform risk mitigation strategies 22 Evolution of Threat Assessment Structured Clinical Judgment • Combines the “best” of clinical and actuarial approaches • Informed by empirical literature • Standard items, often normed • Increased predictive validity over actuarial alone • Informs risk mitigation strategies 23 12

7/28/2016 Sample Structured Clinical Judgment Guides WAVR 21 • S.G. White and J.R. Meloy, 2007 • Workplace Assessment of Violence Risk HCR-20 • C.D. Webster, K.S. Douglas, D. Eaves, S.D. Hart, 1997 • Correctional, Forensic and Civil Psychiatric Assessment of Violence Risk VRAI • Incorporates Veteran-specific risk factors • Evaluation and Implementation FY15-FY16 24 Violence Risk Assessment: How “Good” Are We? Flipping a Coin AUC=.50 Clinical Decision-making AUC=.66 Spousal Abuse Risk Assessment AUC=.70 History of Violence AUC=.71 Psychopathy Checklist AUC=.75 Violence Risk Appraisal Guide AUC=.76 HCR-20 AUC=.80 MacArthur Risk Assessment Study AUC=.82 Perfect Accuracy AUC=1.0 Eric Elbogen, 2014 13

7/28/2016 Bimodal Theory of Violence Predatory vs. Affective 26 J. Reid Meloy (2006) Pathway to Violence Affective Predatory Attack Attack Breach Breach Preparation Research & Ideation Planning Ideation Grievance Grievance Calhoun and Weston (2003) 27 14

7/28/2016 Threat Assessment and Management: Ongoing and Iterative Personal Communication Schouten, Van Male, & Meloy (2015) From Bystander to Upstander: Employees Are Our Key Asset August 2016 15

7/28/2016 • Bystander to “ Upstander ” • Education and Awareness • Skills Van Male, February 2016 PMDB Program Structure • Promotes, Trains, Recalibrates Master Trainers via PMDB Director • Train The Trainer and Annual Recalibration • Train and Recertify Facility Trainers via Master Trainers • Train The Trainer Course and FTRAs • Train and Refresh Frontline Employees via Facility Trainers • Level II, III, and IV of PMDB In-Class Training Front Line • Learn PMDB Skills through 4 Levels of PMDB Employees Training 31 16

7/28/2016 PMDB Employee Curriculum Level I Level II Level III Level IV • Online • In Class • In Class • In Class • Introduction to • Customer Service, • Limit Setting and • Therapeutic Violence Observation, Personal Safety Containment Prevention Assessment, and Skills (Physical (Patient Concepts Verbal De- Protection) intervention to escalation Skills control physically (Verbal violent acts) Protection) 32 Matching PMDB Training Levels to Risk Definitions RISK LEVEL DEFINITION TRAINING NEEDED HIGH Exposure to physical disruptive Levels I, II, III, IV behavior (DB) requiring (Customer Service/Verbal, therapeutic containment Physical Skills, Therapeutic Containment) MODERATE Exposure to both physical and Levels I, II, III verbal disruptive behavior (DB) (Customer Service/Verbal, Physical Skills) Exposure to only verbal Levels I, II LOW disruptive behavior (DB) (Customer Service and Verbal Skills) MINIMAL No exposure to any type of Levels I Only disruptive behavior (DB) Intro. to WVP concepts 17

7/28/2016 Percent Physically Violent Incidents Concentrated in Areas With and Without Mandatory PMDB Employee Training 80 69 70 59 56 60 52 48 50 44 41 40 31 30 20 10 0 ED/ER/UCC CLC Inpatient Psychiatry Med/Surg Inpatient PhysicallyViolent Verbal Vance et al (2014) 18

7/28/2016 Time Saved by Using WBRA and Reduced F2F Training VHA reduced Face to Face (F2F) training hours 81% by using a data- driven process to inform training need and course assignment. Vance et al (2014) Active Threat/Shooter: Considerations in Health Care https://www.google.com/search?sclient=psy-ab&site=&source=hp&q=run%2C+hide%2C+fight&btnK=Google+Search • Patient Abandonment • Sterile Environments • Chemicals, Biohazards • Realistic Expectations of Police Response • Federal Bureau of Investigation, Behavioral Analytics Unit: Targeted Violence in Health Care (Amman, 2015) 19