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  • Writer's pictureDrew Neckar

The Joint Commission Issues New Healthcare Workplace Violence Prevention Accreditation Requirements

Workplace violence directed against healthcare workers has been recognized as a serious issue for quite some time, in fact in the United States the Occupational Health and Safety Administration (OSHA) has deemed workplace violence as a “recognized hazard” for healthcare organizations, requiring that they take preventative measures. Other countries, and individual US States, have also enacted their own programs to combat workplace violence against healthcare workers. In the newest development in healthcare workplace violence prevention on June 18th 2021 The Joint Commission, which provides accreditation for nearly 4,000 hospitals in the US and internationally, published finalized changes to its accreditation standards that will be aimed at making healthcare organizations take a more proactive stance on addressing workplace violence.

The proposed changes will go into effect January 1st, 2022 for Hospital and Critical Access Hospital programs accredited by The Joint Commission, and include the following added requirements and adjustments to the Environment of Care, Human Resources, and Leadership chapters of its standards.

  • Adds an extremely broad definition of "Workplace Violence" to its Glossary which defines workplace violence as "an act or threat occurring at the workplace that can include any of the following: verbal, nonverbal, written, or physical aggression; threatening intimidating, harassing, or humiliating words or actions; bullying; sabotage; sexual harassment; physical assaults; or other behaviors of concern involving staff, licensed practitioners, patients, or visitors."

  • Adds the requirement that the organization conducts an annual assessment of the effectiveness of its workplace violence program and acts on its findings. (EC.02.01.01) It also notes that the worksite analysis needs to include "a proactive analysis of the worksite, an investigation of the hospital’s workplace violence incidents, and an analysis of how the program’s policies and procedures, training, education, and environmental design reflect best practices and conform to applicable laws and regulations."

  • Adds language specifically including “workplace violence Incidents” in the definition of “security incidents” for which the organization must maintain processes to document, monitor, and investigate. It also notes that "a summary of such incidents may also be shared with the person designated to coordinate safety management activities" (EC.04.01.01)

  • Adds language specifically including “workplace violence Incidents” in the definition of “security incidents” which the organization must investigate. (EC.04.01.01)

  • Adds the requirement that the organization provides 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. (HR.01.05.03) This training and resource must include:

    • 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

  • Adds the requirements that the organization maintains a workplace violence prevention program and that the program: (LD.03.01.01).

    • Is led by a designated individual.

    • Is developed by a multi-disciplinary team.

    • Has polices and procedures to prevent and respond to workplace violence.

    • Has a process for reporting and analysis of workplace violence incidents.

    • Has a process to follow-up and support victims of workplace violence.

    • Has a process for reporting of workplace violence incidents to the organization’s governing body.

According to Joint Commission representatives these new standards will be assessed by the TJC Medical Surveyor during the Leadership session, so it will behoove organizations to ensure that their senior leadership teams are well versed in their workplace violence prevention program elements.

While none of the changes place too onerous a burden on the organization they will necessitate changes to existing practices at most organizations, especially small critical access hospitals that do not have dedicated Security resources and hospitals in jurisdictions that do not have well developed national or local laws requiring healthcare workplace violence prevention programs. While hospitals are given some discretion on how they implement these new requirements some key elements they will want to ensure they have in place within the next six months are:

  • The definition the hospital is using for "workplace violence" must align with the definition in Standards.

  • The hospital will need to implement an annual assessment of its workplace violence prevention program which meets all of the required elements, and then document its actions to follow-up any identified areas for improvement. The Joint Commission does not specify who should conduct this analysis, but in the past accreditors have looked favorably on assessments conducted by outside experts in security and violence prevention hired by the organization so it may be beneficial to bring in an outside consulting firm to review processes and identify gaps every few years.

  • It implements a standardized process for reporting, investigation, and documentation of all types of incidents that fall within the definition of workplace violence. While not required, if the organization does not already have an electronic incident reporting tool in place I would recommend implementing one.

  • As part of the investigation process the organization will need to ensure that it has processes in place to provide follow-up and support to both victims and witnesses affected by workplace violence. It is required that these supports include trauma and psychological counseling if necessary, in order to meet this obligation the organization will need a process in its documentation to record all involved persons and may want to consider an process for automatic non-mandatory referral to an employee assistance program for all employees involved.

  • While the organization has some leeway in determining exactly what level of workplace violence prevention training is required for each individual role and in how that training is delivered, it must put a process in place to ensure that it documents training in workplace violence prevention for each staff member at time of hire, annually, and when any changes are made to the organization's workplace violence prevention program. It should also ensure that the effectiveness of this training is assessed as a part of the annual "worksite analysis" of the workplace violence prevention program.

  • That it has policies and procedures in place governing its workplace violence prevention program, and perhaps more importantly that any policies or procedures it has are being followed.

  • These policies and procedures and the rest of the workplace violence prevention program must be developed by a multi-disciplinary team. There is no specificity of the membership of this team, but in my experience it should include representation from Security, Safety, Human Resources, Senior Leadership, Physicians, Nursing, Facilities, and other key areas identified as having a higher risk of incidence of workplace violence.

  • An single named individual is officially designated to lead the organization's response to workplace violence and has responsibility and accountability for ensuring that the program meets requirements. The Joint Commission does not specify who this individual should be, but I recommend someone at a leadership level with responsibility for a portion of the workplace violence prevention program.

  • There is a process in place, that is reflected in meeting minutes or other documentation, for reporting all incidents of workplace violence to the hospital's governing body. This will be a new process for many organizations as I have seen few hospitals that routinely include workplace violence reporting in the agenda for their Board of Directors meetings. It should also be noted that with this requirement it may increase the organization's potential liability if sued after a workplace violence incident as prior incidents will be easily discoverable by plaintiff's counsel and may go a long way in demonstrating foreseeability.

The full prepublication standards can be found at:

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