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    Christian Green
    Christian Green, MA

    Violence in the workplace is an ever-growing issue in the United States, particularly in the healthcare industry. This has been even more apparent during the COVID-19 pandemic: Increased levels of anxiety and stress, perceived loss of control by patients and their families and staffing shortages have contributed to increased risk of violence for healthcare workers.

    According to the Occupational Safety and Health Administration (OSHA), workplace violence is defined as “any act or threat of physical violence, harassment, intimidation, or other threatening disruptive behavior that occurs at the work site. It ranges from threats and verbal abuse to physical assaults and even homicide.”1

    Some key statistics reveal its prevalence in healthcare:

    • The industry has more than five times the rate of violence than all other industries.2
    • Between 2011 and 2018, the number of days away from work caused by nonfatal workplace violence injuries and illnesses increased from 8,180 to 15,230. The number for 2018 was nearly five times that of all other industries.3
    • 75% of nearly 25,000 workplace assaults occur annually in healthcare and social service settings.4

    Although employers aren’t required to institute workplace violence prevention programs under OSHA guidelines, medical practices should consider developing emergency action plans to help protect staff, providers and patients. As Rana McSpadden, FACMPE, CPC, CEMA, medical practice consultant and analyst, State Volunteer Mutual Insurance Company (SVMIC), Brentwood, Tenn., points out, “We have plans when it comes to fires and tornadoes; however, we also need to have a plan for how we are going to address workplace violence and those active-shooter situations … we need to be aware of how we are going to react in the event that should happen.”

    Emergency action plan

    An emergency action plan starts with laying out a preferred method for reporting emergencies. For example, practices should have a panic button or a speaker phone to notify staff and providers that there’s a situation in the building. Some practices may have code words that correspond to a particular emergency and location. However, oftentimes, not everyone in the office is familiar with every code, which could mean the difference between life and death when every second counts.

    “It’s actually being recommended now that instead of having code words, you say, ‘active shooter, lobby,’ or ‘fire, kitchen,’” McSpadden says of the need to identify the situation and location in a way that makes anyone else in the office aware.

    Evacuation versus escape

    Once a reporting method has been established, practices should determine evacuation and escape procedures, which McSpadden notes are different: “An evacuation procedure is you’re not only going to get out of the building, you’re also going to make sure everyone else is out of the building.” Whereas, an escape procedure involves utilizing floor maps, including the location of escape routes and safe areas. “Floor maps are very important especially if your route of evacuation or emergency exit doors aren’t properly indicated,” McSpadden asserts.

    Emergency communications

    Practices should also have local hospital information on hand, particularly in rural areas where it’s imperative to know the proximity of the closest hospital. McSpadden adds that you want to have a plan in place for how you’re going to notify hospitals if there’s an incident. The same holds true for law enforcement. “911 is always the easiest way to contact law enforcement, but maybe you’re in an area that’s not close to a police station or maybe there is a police station close by, and you can contact them easier by contacting them directly,” McSpadden says.

    Practices also need to gauge their ability to respond to a security threat via a security system or alarm, and know approximately how long it will take for law enforcement to respond based on the distance from the office.

    Security policies

    One of the first steps practices should take regarding security policies is to conduct a security and vulnerability assessment (SVA) for each location, because each is likely set up differently. Practices will want to review environmental risk factors that could put them at risk for violence. As McSpadden observes, practices should evaluate how individuals can gain access and avoid detection. Are there “unlocked back doors that anybody can walk in? Insufficient lighting, dark parking lots, blind corners? Are there big bushes right next to the back door where your employees go in and out where somebody could hide?”

    McSpadden says it’s also vital to look at environmental stressors such as confusing signage, difficult parking or building access, disturbing noise levels, long wait times or even insufficient heat or air.

    McSpadden recalled a staff member who became outwardly upset and began yelling about the office temperature. “She was in a small office working with another individual … she felt she was always cold, and there was no way that we could really balance the temperature out,” McSpadden said. “What happens is that they get to that tipping edge that something just throws them over, and they’re like, ‘I’m done,’ or ‘I’m out,’ or they just get angry or yelling or even become violent.”

    McSpadden says practices also need to recognize opportunistic weapons individuals can use in the office, whether used to attack someone or in defense, such as unsecured furniture, fixtures or decorative items.

    In addition, assessing zero tolerance versus tolerance recognition and response is critical because not every case is black and white, according to McSpadden. “Zero tolerance policies keep those staff members who are being attacked from fighting back and defending themselves,” McSpadden says, also pointing out that a slight shove needs to be treated differently than a punch in the face. The former may warrant a suspension rather than a firing.

    It’s also important to establish protocols for reporting incidents, whether that involves reporting it to an HR director or a manager, and how the situation’s going to be investigated. “Figure out what’s going on with that individual who is reporting it,” McSpadden says. “You also need to interview the person who they are reporting it against,” along with interviewing witnesses and then taking appropriate actions, whether that’s counseling, involving law enforcement or firing the individual, she notes. 

    Security and vulnerability assessment in practice 

    When assessing your practice, consider the following questions to ensure compliance and document ways for improvement.

    Physical security

    • Do you have staff ID badges?
    • Is there a secure parking area for staff?
    • Are all exits in your practice clearly marked?
    • Does your office have a functional alarm system?

    Human resources practices

    • Does HR conduct pre-employment screenings, including background checks and drug tests?
    • Does HR conduct regular performance reviews and evaluate employee happiness?


    • How does your staff communicate with each other, as well as with patients and vendors?
    • Are staff and patients treated with respect?
    • Are staff and patients given the opportunity to voice their opinions and concerns?


    • Are staff trained in preventing sexual harassment and workplace violence?
    • Is management trained in conflict management, effective communication and problem-solving?

    Incident assessment/investigation and documentation

    • Do you have a workplace violence prevention program?
    • Do you have a documented process for responding to and investigating incidents?

    Agency relationships

    • Have you introduced yourself and developed a relationship with the closest law enforcement agency?
    • Do you have an employee assistance program?

    Responding to threats and acts of violence

    • Do you have documented procedures for responding to verified threats and acts of workplace violence?
    • Do you have a zero-tolerance policy for threats and acts of workplace violence?

    Investigation and evaluation of incidents

    • Do you record detailed information about each workplace violence incident?
    • Do you have a workplace violence prevention team that meets regularly to review workplace violence incidents?

    Warning signs of workplace violence

    According to McSpadden, one of the most important aspects of workplace violence prevention is educating employees. “If you recognize these warning signs, you may be able to squash anything that’s going to come down the pike,” McSpadden says of being proactive. Some of the key warning signs include:

    • Staring, intense eye contact or lack of eye contact
    • Tone or volume of voice
    • Anxiousness
    • Mumbling under breath
    • Pacing. 

    If your staff observes any of the above, there’s a better chance you will be able to intervene before things turn violent.
    Beyond these general warning signs, McSpadden says there are five underlying issues to keep an eye out for with co-workers:

    1. Changes in mood/personal hardships — heightened belligerence, hypersensitive to criticism, outbursts of anger, increased absenteeism from work
    2. Mental health issues — anxiety, depression, homicidal/suicidal comments or threats, substance abuse
    3. Negative behavior — bad attitude, co-worker grievance, fixation with violence, lying, obsession with someone at work, untrustworthiness
    4. Verbal abuse — bullying (including the victim lashing out), intimidation, name-calling, threats
    5. History of violence — domestic abuse, prior arrests or convictions.

    By becoming attuned to these signs and having an emergency action plan in place, McSpadden says employees will be better prepared to address the situation. It’s important for staff “to develop that muscle memory” so that “their body is already moving, getting out of the way and doing what they’re supposed to do,” McSpadden maintains.

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    Dig deeper

    • Annual Compliance Recommended Training Checklist — This downloadable tool outlines requirements for medical practices:
    • MGMA OSHA Medical Practice Compliance: Fillable Form Book — This automated eBook helps expedite OSHA compliance in your medical practice, generating all applicable forms:
    • “Start the new year by reviewing your compliance policies” — An overview of annual compliance needs, including HIPAA, medical records, False Claims Act, human resources and more:
    • “How robust is your practice’s emergency planning and disaster preparedness?” — Includes the MGMA Emergency Planning Checklist:


    1. “Workplace violence.” United States Department of Labor — Occupational Safety and Health Administration. Available from:
    2. “Fact Sheet, Workplace Violence in Healthcare, 2018.” Updated April 2020. U.S. Bureau of Labor Statistics. Available from:
    3. Ibid.
    4. “Physical and verbal violence against healthcare workers.” The Joint Commission. April 17, 2018. Available from:
    Christian Green

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