VIOLENCE: AN OSHA PERSPECTIVE FROM THE OFFICE OF OCCUPATIONAL MEDICINE AND NURSING Michael J Hodgson, MD, MPH Chief Medical Officer and Director, Office of Occupational Medicine and Nursing
Background No explicit federal regulations address workplace violence OSHA uses the General Duty Clause [5(a)(1)] to enforce violence cases External interests Senators sent a letter In 2016 OSHA was petitioned for a standard by a coalition of labor unions GAO has been examining our performance Several states have local regulations that address workplace violence In 1994, California became the first state to pass a workplace violence law when it enacted the Workplace Violence Safety Act In 2005, Illinois enacted the Health Care Workplace Violence Prevention Act
States with Enhanced Penalties for Violence against Health Care Workers Source: Emergency Nurses Association (https://ena.org/government/state/pages/default.aspx
OUTLINE Recent data BLS SIR Materials Guidelines CMS / OSHA iniative Recent OSHA activities Enforcement Evaluation of education programs Assessment of 5(a)(1) versus Hazard Alert Letter
25.0 ASSAULT RATES 2011 2014 Cases per 10,000 workers 20.0 15.0 10.0 5.0 0.0 C2011 C2012 C2013 C2014 Crop production Construction Hospitals Residential facilities All industry 5 Bureau of Labor Statistics 10 / 2016
INTENTIONAL INJURY BY ANOTHER PERSON Rate per 10,000 workers 9 8 7 6 5 4 3 2 1 0 Y2011 Y2012 Y2013 Y2014 Natl HCW Educat Bureau of Labor Statistics 10 / 2016
ASSAULT RATES IN HEALTH CARE SECTORS 2011 2014 Cases per 10,000 workers 150.0 100.0 50.0 0.0 C2011 C2012 C2013 C2014 Offices of physicians Home health care General Hospitals Other Hospitals Residential Mental Health Other residential Care Failities Outpatient care centers Other ambulatory services Psychiatric Hospitals Nursing Care Community Elderly Facilities All Industry Bureau of Labor Statistics 10 / 2016 7
Frequency of Healthcare Violence by Facility Type 4% 4% 8% 4% 4% 8% 8% 56% 4% General Hospitals Skilled nursing care Continuing care facilities Other individual family services Vocational Rehabilitation Psychiatric Hospitals Residential Substance abuse Assisted living Other community housing Severe Injury Reports through 4/2016
100 Workplace violence resulting in amputation 80 60 40 20 0 Hospitalized Frequency Percent Yes
VIOLENCE PERPETRATORS IN VARIOUS INDUSTRIES 60 50 40 30 20 Type 3 Type 2 Type 1 10 0 Healthcare Trade All others
Frequency of workplace violence by 40 35 30 25 20 15 10 5 0 industry Type 1 Type 2 Type 3
35.0 Workplace violence percentage by industry 30.0 25.0 20.0 15.0 10.0 5.0.0
Frequency 14 12 10 8 6 4 2 0 Mechanism of workplace violence (n=25) 13 7 1 1 3 Mechanism Severe Injury Reports through 4/2016
Category of healthcare violence (n=25) 8% 92% Type 1 (criminal intent) Type II (patient) Severe Injury Reports through 4/2016
50 45 40 35 30 25 20 15 10 5 0 Intent (%) for healthcare violence Severe Injury Reports through 4/2016
Inter rater agreement for forensics intent 12 10 8 6 4 2 0 Predatory Affective Severe Injury Reports through 4/2016
OSHA VIOLENCE PREVENTION GUIDELINES FOR HEALTHCARE AND SOCIAL SERVICES 2015 CONTENTS 1. Management Commitment and Worker Participation..... 6 2. Worksite Analysis and Hazard Identification............ 8 3. Hazard Prevention and Control....................... 12 4. Safety and Health Training........................... 24 5. Recordkeeping and Program Evaluation................ 27 CHECKLISTS Area Program
IMPLEMENTATION TOOLS Roadmap for violence prevention (OSHA/CMS) https://www.osha.gov/publications/osha3827.pdf Examples for implementation List of OSHA tools and publications on violence prevention https://www.osha.gov/dcsp/alliances/healthcare.html
OSHA INTERNAL ACTIVITIES Enforcement Program evaluations Investigation of 5(a)(1) v HAL
transportation security retail other health 0 50 100 150 200
DISTRIBUTION OF INDUSTRIES BY 90 80 70 60 50 40 30 20 10 0 FISCAL YEAR OF EVENTS FY2004 FY2007 FY2010 FY2011 FY2012 FY2013 FY2014 FY2015 FY2016 health other retail security transportation
OUTCOME OF INSPECTION BY FISCAL 90 YEAR 80 70 60 50 40 30 20 10 0 FY2004 FY2007 FY2010 FY2011 FY2012 FY2013 FY2014 FY2015 FY2016 No citation 5(a)(1) HAL Active
3.5 RATIO OF 5(a)(1) CITATIONS TO HAZARD ALERT LETTERS AND OF 5(a)(1) CITATIONS to NOTHING 3 2.5 2 1.5 1 0.5 0 R1 R2 R3 R4 R5 R6 R7 R8 R9 R10 5a1:HAL 5a1:nothing
Frequency of enforcement visits by healthcare facility type Vocational Rehabilitation Other community housing Other individual family services Assisted living Continuing care facilities Residential Substance abuse Skilled nursing care Psychiatric Hospitals General Hospitals 0 1 2 3 4 5 6 7 8 9 101112 Field visit initiated No field visit initiated
Graphic Comparison of 12 Reviewed Programs to Review Criteria Facility policies 25% 17% 58% Facility specific risk factors 17% 8% 75% Early recognition 92% 0% 8% Teach de escalation 100% 0% Evasion/extrication 92% 0% 8% Restraints and holds 92% 0% 8% Yes signficant evidence Predatory violence Team approach 25% 0% 92% 75% 0% 8% Yes limited evidence Reporting violence 8% 8% 83% Multicultural info 25% 0% 75% Worker Follow up 17% 25% 58.30% Program evaluation 25% 33% 41.70% 0% 20% 40% 60% 80% 100%
Project Methods 1. Literature review on WPV and prevention programs 2. Identified 5 recent 5(a)(1) and 3 HALS on WPV 3. Modified existing checklist (2015 OSHA Guidelines) 4. Interviewed CSHOs who investigated the WPV cases 5. Collaborated with national violence prevention experts on modification of program evaluation checklists 6. Compared existing laws and programs for essential elements: modified checklists 7. New questions
Rate of Gaps Identified in Employers WPV Programs WPV Prevention Program Checklist Elements Five Total 5(a)(1) Citations Reviewed Three Total HALs Reviewed 1. Written WPV program 60% 67% 2. Management commitment/employee participation 3. Threat assessment and management 4. Hazard prevention and control 80% 67% 80% 67% 100% 33% 5. Training program 100% 67% 6. Data systems 100% 67%