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Establishing a Workplace Violence Prevention Program for FQHCs


Establishing a Workplace Violence Prevention Program for FQHCs 2011 FACHC Clinician's Network Conference April 15, 2011 Amelia Muccio Director of Emergency Management – PowerPoint PPT presentation

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Title: Establishing a Workplace Violence Prevention Program for FQHCs

Establishing a Workplace Violence Prevention
Program for FQHCs 2011 FACHC Clinician's Network
Conference April 15, 2011
Amelia Muccio Director of Emergency
  • Recognize common warning signs of violent
  • Understand the steps you can take to prevent
    workplace violence, or effectively respond if it
  • Policies/Plans needed
  • Training necessary
  • Exercising your facilitys plans/training
  • Establishing a culture of safety and preparedness

Inflection of Voice ExamplesHow We Communicate
  • I didnt say you were stupid
  • I didnt say you were stupid
  • I didnt say you were stupid
  • I didnt say you were stupid
  • I didnt say you were stupid

Hazard Vulnerability Analysis
  • Identifies potential emergencies and the
    direct/indirect effects these emergencies may
    have on CHCs operation and demand for services
  • The risks identified should be prioritized based
    on likelihood of occurrence and severity

HVA with Workplace Violence, N15
Workplace Violence is a Growing Concern
  • Violence in workplace causes significant number
    of workplace fatalities and injuries.
  • Annually, 1.7 million American workers are
    directly affected by assaults and violent acts.
  • The healthcare sector lead all other industries
    with 45 of all nonfatal assaults against workers
    resulting in lost work days in US.
  • Can strike anywhere, at anytime.

What is Workplace Violence?
  • Workplace violence is often thought of as a
    physical attack. But it may also include threats,
    intimidation, and other disruptive behavior, oral
    or written statements, and gestures or
    expressions that communicate a direct or indirect
    threat of physical harm.
  • Physical Psychological
  • Threats/Harassment
  • Physical abuse
  • Cyber harassment
  • Bullying
  • Intimidation
  • Yelling/Cursing

Four Types of Workplace Violence
  • Type 1 Criminals/Strangers
  • Type 2 Customers/Clients
  • Type 3 Employees/Coworkers
  • Type 4 Related Parties/Personal Relations

Violence Violence by Criminals/Strangers
  • Type 1 violence includes violent acts by
    criminals who have no other connection with the
    workplace, but enter to commit robbery or another
  • Such violence accounts for the vast majority
    (nearly 80 percent) of workplace homicides. The
    motive is usually theft.
  • In many cases, the criminal is carrying a gun or
    other weapon, increasing the likelihood that the
    victim will be killed or seriously wounded.

Code Silver SOP (Hostage Situation)
  • 4 sectionsMitigation, Preparedness, Response and
  • Review HVA
  • ICS/Job Action Sheets
  • Call down procedure
  • Floor plans
  • Head count
  • Develop AAR

Active Shooter SOP
  • 4 sectionsMitigation, Preparedness, Response and
  • Crisis Kits
  • Access controls
  • Active Shooter training plan (recognizing gun
  • Evacuate (2 routes)
  • Hide Out (door opens in, locked, barricade)
  • Take action (last resort)

Violence by Customers/Clients
  • Type 2 includes violence directed at employees by
    customers, clients, patients, students, inmates,
    or any others for whom an organization provides
  • Such violence can be very unpredictable.
  • It may be triggered by an argument, anger at the
    quality of service, denial of service, delays, or
    some other precipitating event.

Code Gray SOP (Combative Patient or Security)
  • 4 sectionsMitigation, Preparedness, Response and
  • Warning signs
  • Reporting
  • Policies and procedures
  • Staff training
  • Confidential process
  • Support system

Violence by Employees/Coworkers
  • The third type of workplace violence consists of
    acts committed by a present or former employee.
  • Such violence may be directed against coworkers,
    supervisors, or managers.
  • Internal/External pressures, long hours, etc, may
    increase stress and interfere with an
    individuals ability to cope.

Behavior and Warning Signs
  • Regardless of the type of workplace violence, the
    chances for prevention improve with increased
    awareness of potential warning signs and rapid
    response to a potential problem.
  • No one can predict human behavior, and there is
    no specific profile of a potentially dangerous
    individual. However, studies indicate that
    incidents of violence are usually preceded by
    patterns of behavior or other activities that may
    serve as warning signs.
  • While there are no fail-safe measures to ensure
    that violence will never occur, early action and
    intervention can serve to defuse a potentially
    dangerous situation and minimize the risk of

Warning Signs of Employee/Coworker
  • -Increased use of alcohol and/or illegal drugs
  • -Unexplained increase in absenteeism
  • -Noticeable change in appearance or hygiene
  • -Depression/Withdrawal
  • -Resistance overreaction to changes in policy
  • -Repeated violations of company policies
  • -Severe mood swings
  • -Noticeably unstable, emotional responses
  • -Explosive outburst of anger or rage w/o
  • -Suicidal comments
  • -Behavior which is suspect of paranoia
  • -Increasingly talks of problems at home
  • -Escalation of domestic problems in the workplace
  • -Talk of previous incidents of violence
  • -Empathy with individuals committing violence
  • -Increase in unsolicited comments about firearms,
    other dangerous weapons and violent crimes

Performance Indicators
  • Attendance problems, such as excessive sick
    leave, excessive tardiness, leaving work early,
    or improbable excuses for absences.
  • Decreased productivity, including making
    excessive mistakes, using poor judgment, missing
    deadlines, or wasting work time or materials.
  • Inconsistent work patterns, such as alternating
    periods of high/low productivity or quality of
    work, exhibiting inappropriate reactions,
    overreacting to criticism, or mood swings.
  • Concentration problems, including becoming easily
    distracted or having difficulty recalling
    instructions, project details, or deadline
  • Adverse effect on supervisor's time when he or
    she must spend an inordinate amount of time
    coaching and/or counseling the employee about
    personal problems, redoing the employee's work,
    or dealing with coworker concerns.

Behavioral Indicators
  • Continual excuses and blaming, such as an
    inability to accept responsibility for even the
    most inconsequential errors.
  • Safety issues, including a disregard for
    personal, equipment, and machinery safety or
    taking needless risks.
  • Unshakable depression, as exhibited by low
    energy, little enthusiasm, and/or despair.
  • Evidence of serious stress in the employee's
    personal life, such as crying, excessive personal
    phone calls, or recent change in
    family/relationship status.
  • Unusual or changed behavior, such as
  • Inappropriate comments, threats, throwing
    objects, etc.
  • Evidence of possible drug or alcohol use/abuse.
  • Poor health and hygiene (marked changes in
    personal grooming habits).

Violence by Related Parties/Personal Relations
  • Type 4 includes violence committed in the
    workplace by someone who doesnt work there, but
    has a personal relationship with an employeefor
    example, an abusive spouse or domestic partner.
  • In such cases, there is a greater chance that
    warning signs were observed, but
    ignoredcoworkers or managers may have believed
    the signs were not important or were none of
    their business.

Domestic Violence
  • DV is a pattern of coercive tactics which can
    include physical, psychological, sexual, economic
    and emotional abuse perpetrated by one person
    against an adult intimate partner with the goal
    of establishing and maintaining power and control
    over the victim.

Domestic Violence at the Workplace
  • Some abusive partners may try to stop women from
    working by calling them frequently during the day
    or coming to their place of work announced.
  • Research indicates that about 50 of battered
    women who are employed are harassed at work by
    their abusive partners.

Confidential Policy for Domestic Violence
  • Anti-Violence policies work best when there is
    also a general policy of confidentiality letting
    the victim know that their confidentiality will
    be maintained to the extent possible and
    underscore safety and respect for privacy.
  • De-Stigmatize domestic violence to increase
  • Custody dispute, divorce, separation and other

Policies and Procedures
  • Establish security culture
  • Establish best security practices
  • Define goals and structure of security program
  • Educate personnel
  • Maintain compliance with any regulations
  • Informational materials/signage
  • Partnership with local resources
  • Mental health administrators

  • The best prevention strategy is to maintain an
    environment that minimizes negative feelings,
    such as isolation, resentment, and hostility
    among employees.
  • Although no workplace can be perceived as perfect
    by every employee, management can help create a
    professional, healthy, and caring work

  • Promote sincere, open, and timely communication
    among managers, employees, and union
  • Offer opportunities for professional development.
  • Foster a family-friendly work environment.
  • Maintain mechanisms for complaints and concerns
    and allow them to be expressed in a nonjudgmental
    forum that includes timely feedback to the
  • Promote quality of life issues such as pleasant
    facilities and job satisfaction.
  • Maintain impartial and consistent discipline for
    employees who exhibit improper conduct and poor

Reporting Policy
  • Report violent acts or threats of violence to
    your immediate supervisor.
  • Information regarding a threat of a harmful act,
    where you reasonably believe that the
    circumstances may lead to a harmful act, should
    be reported immediately.

Workplace Violence Reporting
  • All reports of incidents involving workplace
    violence will be taken seriously and dealt with
  • Individuals who commit such acts may be removed
    from the premises and may be subject to
    disciplinary action, criminal penalties, civil
    litigation, or all of the above.

Confidentiality Policy
  • Managers and supervisors should preserve the
    confidentiality of employee complaints.
  • Share information only with those who have a need
    to know in order to carry out official business.
  • Protect incident reports, related information,
    and the privacy of persons involved, just as in
    other sensitive and confidential personnel
  • However, there is an exception when there is
    evidence of a direct threat or potential harm to
    self or others.

Confidentiality Policy, N15
Security Policies
  • Maintaining a secure and physically safe
    workplace is part of any good strategy for
    preventing workplace violence.
  • Employee photo identification badges.
  • Onsite guard services.
  • Guard force assistance in registering and
    directing visitors in larger facilities.
  • Other appropriate security measures (e.g., metal
  • Employees should notify the appropriate security
    office or designated police about suspicious or
    unauthorized individuals on agency property.
  • Additional law enforcement assistance is
    available through local police departments for
    emergency situations.

Human Resources Policies
  • Employees and managers can always receive
    assistance from the Human Resources/Human Capital
    Division regarding inappropriate behavior in the
  • Inappropriate behavior includes fighting as well
    as threatening, intimidating, harassing,
    disruptive, or other harmful behavior.

Support Services Available
  • There are many avenues and types of support
    services available for employees to prevent
    workplace violence.
  • Some forms of prevention include training, stress
    management programs, and enhanced communication
    by management team and with other employees,
    security personnel, stress managers and health
    professionals, and union representatives.
  • Employee Assistance Program (EAP)

Education Component
  • Education and communication are also critical
    components of any prevention strategy. In
    addition to workplace violence training such as
    this course, educational offerings on the
    following topics may be useful
  • Communications
  • Conflict resolution
  • Anger management
  • Stress reduction

Verbal De-Escalation Training for Staff
  • In service with a trained professional
  • Does plan include/reflect training?
  • Exercise these skills in role playing and formal

Exercise your Plan
  • Mad World Tabletop Exercise (TTX)
  • Tests and validates Centers VIWP policies,
    plans, and procedures
  • Players
  • Team-Centered Approach/Multi-Disciplinary
  • EAP/HR
  • Center Leadership
  • Security
  • Essential Functions

Warning Sign Levels
  • Warning signs of violent behavior may be
    classified into three levels.
  • Not everyone exhibiting warning signs will become
    violent. However, no warning sign should be
    completely ignored. Any one or combination of
    warning signs, at any level, may indicate a
    potentially violent situation.
  • Level 1 Intimidation
  • Level 2 Escalation
  • Level 3 Further Escalation

Level 1Intimidation
  • In Level 1, the person exhibits intimidating
    behaviors that are
  • Discourteous/disrespectful,
  • Uncooperative, and/or
  • Verbally abusive.

Employee Responses
  • Observe and document the behavior in question.
  • Report his or her concerns to the supervisor to
    seek help in assessing and responding to the
  • One technique for addressing the situation in a
    respectful manner and establishing limits with
    the offending coworker is the use of I
    statements, such as
  • I dont like shouting. Please lower your voice.
  • I dont like it when you point your finger at
  • I want to have a good working relationship with

Supervisor Responses
  • The supervisor should meet with the offending
    employee to discuss the concerns.
  • If the offending employee is the reporting
    employee's immediate supervisor, the employee
    should notify the next level of supervision.
  • If the offending person is not an employee, the
    supervisor of the employee reporting the incident
    is still the appropriate individual to receive
    the information and provide initial response.

Level 2Escalation
  • Argue with customers, vendors, coworkers, or
  • Refuse to obey agency policies or procedures.
  • Sabotage equipment or steal property for revenge.
  • Verbalize wishes to hurt coworkers or management.
  • Stalk, harass, or show undue focus on another
  • Make direct or indirect threats to coworkers or
    management (in person, in writing, by phone).
  • View himself or herself as victimized by
    management (me against them) and talk about
    getting even.

Employee Responses
  • Call 911, if warranted.
  • Secure the safety of self and others, if
  • Immediately contact the supervisor.
  • Document the observed behavior in question.

Supervisor Responses
  • The supervisor should consult with officials,
    such as functional area experts, for help in
    assessing/responding to the situation.
  • Avoid an audience. Remain calm, speaking slowly,
    softly, and clearly.
  • Ask the employee to sit, to see if he or she is
    able to follow directions.
  • Ask questions about the complaint, such as
  • What can you do to regain control of yourself?
  • What can I do to help you regain control?
  • What do you hope to gain by committing violence?
  • Why do you believe you need to be violent to
    achieve that goal?
  • Direct aggressive tendencies into other
    behaviors, so the employee sees that there are
    choices about how to react.

Level 3Further Escalation
  • Level 3 usually results in some form of emergency
    response. In such cases, the person displays
    intense anger resulting in
  • Suicidal threats.
  • Physical fights or assaults of coworker(s) or
  • Damage or destruction of property.
  • Concealment or use of a weapon to harm others.
  • Display of extreme rage or physically aggressive
    acts, throwing or striking objects, shaking
    fists, verbally cursing at others, pounding on
    desks, punching walls, or angrily jumping up and

  • Call 911 or other appropriate emergency contacts
    for the facility.
  • Secure your personal safety firstleave the area
    if safety is at risk.
  • Remain calm and contact the supervisor.
  • Contact other people who may be in danger. Keep
    emergency numbers for employees up to date and
  • Cooperate with law enforcement personnel when
    they have responded to the situation. Be prepared
    to provide a description of the violent or
    threatening individual, details of what was
    observed, and the exact location of the incident.

If Violence Occurs
  • Sometimes, despite everyone's best efforts to
    defuse a situation, actual violence occurs.
  • If this happens, remain calm and do not put
    yourself or any staff member in a position to be
  • You should call the appropriate officials for
  • Once the danger has passed, take appropriate
    disciplinary action.

Disciplinary Action for Extreme Misconduct
  • In cases of extreme misconduct, the supervisor
    meet with the employee and advise him or her that
    the conduct is unacceptable and access to the
    building has been restricted until further
    notice. The employee is escorted from the
    building by security, and keys and ID are
  • The employee is placed on administrative leave
    until it is decided what, if any, action will be
    taken against the employee.
  • An investigation is conducted to determine
    whether further action is warranted, such as
    suspension or removal, or some lesser action as

Disciplinary Action for Less Extreme Misconduct
  • For less extreme misconduct, a first offense
    should result in counseling between the
    supervisor and employee, as well as a verbal or
    written warning.
  • In the case of a second non-extreme offense, a
    letter of reprimand should be placed in the
    employees Official Personnel Folder.
  • A third offense should result in a proposed
    suspension or proposed removal, as determined

Managing the Consequences of Violence
  • Tend to medical and psychological needs
  • Report incident to law enforcement
  • Secure work area
  • Notify the families of individuals affected

Recovering from Violence Incidents
  • Short and long term psychological trauma
  • Fear of returning to work
  • Changes in relationships with coworkers and
  • Feelings of incompetence, guilt or powerlessness
  • Fear of criticism by leaders or supervisors

Debriefing After Action Reports
  • If violence in the workplace occurs, provide the
    necessary psychological support for staff,
    patients, etc.
  • Provide a debriefing session
  • Write up incident using a corrective action
    format so the organization can learn lessons from
    the event.
  • Strengthens
  • Areas of Improvements

Violence Intervention Techniques (1 of 2)
  • When an employee exhibits signs of violence and
    the situation is not life threatening, defuse the
    anger by using the following techniques
  • Meet with the employee in private to discuss the
    inappropriate behavior. Build trust by listening
    and treating the employee with respect.
  • Do not argue, get defensive, or be sarcastic.
  • Take all threats or acts of violence seriously.
  • Counsel the employee about the misconduct and how
    it affects the work of other employees, with a
    specific warning on future disciplinary action if
    behavior continues.

Violence Intervention Techniques (2 of 2)
  • If you are unable to defuse the situation and the
    threat of violence persists
  • Remain calm and do not put yourself or any staff
    member in a position to be injured.
  • If you are meeting alone with the employee, ask
    the employee to remain and excuse yourself from
    the meeting.
  • Call the appropriate officials for assistance as
  • After the situation has calmed down, counsel the
    employee in writing on the effect of the violent
    behavior and initiate appropriate disciplinary
    action based on the misconduct and/or disruption.

Defusing Strategies
  • Adrenal cocktaildo not escalate
  • Calm, confident
  • Speak slowly, clearly, gently
  • Lower your voice
  • Listen
  • Create some space
  • Adopt a non-threatening body posture (open)
  • Reduce eye contact and keep both hands visible
  • Avoid audiences when possible

Verbal De-Escalation
  • Verbal de-escalation tactics that are
    non-physical skills used to prevent a potentially
    dangerous situations from escalating into a
    physical confrontation or injury.

De-Escalation Techniques
  • Reasoning with an angry person is not possible.
  • The first and only objective in de-escalation is
    to reduce the level of agitation so that
    discussion becomes possible.
  • De-Escalation techniques are inherently abnormal.
  • They go against our natural fight or flight
  • To be effective, we must remain calm and centered
  • We need to be professionally detached.

Verbal and Non-Verbal Techniques
  • Distracting the other person
  • Re-Focus the person
  • Give choices
  • Listen and emphasize
  • Set limits
  • Control your breathing, voice, body language and

Positive and Helpful Statements
  • I want to help you
  • Please tell me more so I better understand how to
    help you
  • Put yourself on his/her side of finding a
    solution to the problem

Role Play
  • Mrs. Ernie is a patient at your Center. Mr.
    Ernie, her husband, enters your Center and is
    visibly agitated upon arrival. He discovered his
    wife is taking birth control pills a decision he
    disagrees with and has come to your Center to
    confront Mrs. Ernies doctor. He is at your
    front desk, in front of a full waiting room and
    begins screaming negative comments and
    profanities. How do you react? How do you
    defuse? Who should situation be reported to?

Role Play
  • On a very busy day at your health center, an
    argument erupts between two coworkers. In front
    of several staff and dozens of patients, two
    employees engage in a loud argument over
    differences in opinion. The situation is being
    watched by all the patients. How do you react?
    What should you do to defuse the situation? How
    should this situation be addressed by management?

  • FEMA Courses
  • IS-106.11 - Workplace Violence Awareness Training
  • IS-906 - Workplace Security Awareness
  • IS-907 - Active Shooter What You Can Do
  • Phil McCabe of UMDNJ SPH