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    Spencer Hamer, ESQ.

    A new law — California Senate Bill 1299 (SB-1299), which takes effect July 1, 2016 — addresses violence in medical facilities. The law requires certain healthcare employers to adopt violence prevention plans. It was passed in response to a spike in nonfatal assaults in the healthcare and social assistance industries during the past eight years.

    This is not the first attempt to prevent workplace violence in hospitals through legislation. In 1993, California passed the California Hospital Security Act, which was designed to reduce violence in hospitals. Most states have enhanced criminal penalties for assaulting nurses, and the American Nurses Association, Silver Spring, Md., created a model state bill to prevent violence against nurses.

    “California is always a bell-weather state and other states look to it for tighter legislation,” says Laura Palmer, FACMPE, senior fellow, MGMA Professional Development. “When I was working with practices in Texas, we watched California very closely as it seemed that within two to three years many of its mandates became widespread. Domestic violence is an issue that occurs in even small practices; I've worked in two offices where a former spouse came in brandishing a gun and in one clinic, a nurse was killed by her ex-husband's new spouse in the parking lot of the building with 14 witnesses.  It's out there and it's in the news everywhere.”

    Kenneth Hertz, FACMPE, principal, MGMA Health Care Consulting Group, concurs. “Medical groups are not immune to this type of violence. Practices need to be concerned about this in order to protect their patients and employees, and to provide as secure an environment as possible for the delivery of healthcare.”

    On a general level, several states require employers to have workplace violence programs, studies or incident reporting, and the Occupational Safety and Health Administration, Washington, D.C., has promulgated general guidelines and recommendations for preventing workplace violence. However, as this issue of MGMA Connection goes to press, no other state had passed legislation as comprehensive as California’s new bill.

    A spike in violence

    Violence in the healthcare field has become an acute problem, and awareness of the issue is starting to increase. In 2007 nearly 60% of all nonfatal workplace assaults and violent acts occurred in the healthcare and social assistance industries, according to the California Nurses Association, Oakland, Calif. Almost 75% of these incidents were assaults by residents of a healthcare facility. In a 2014 survey, almost 80% of nurses reported being attacked on the job in the past year. The Bureau of Labor Statistics (BLS), Washington, D.C., reports that attacks on healthcare workers account for 70% of nonfatal workplace assaults causing days away from work. And the BLS has found that workers in the healthcare and social assistance industries are nearly five times as likely to become the victims of a nonfatal assault or violent act by another person as workers in all other major industries combined.

    In addition, the rate of violent crime in medical facilities has been increasing. Violent crime in hospitals in 2013 was 25% higher than in 2012, according to the International Association for Healthcare Security and Safety, Glendale Heights, Ill. The violent crime rate per 100 hospital beds increased from two incidents in 2012 to 2.5 last year, while the rate of disorderly conduct incidents increased from 28 per 100 hospital beds in 2012 to 39.2 in 2013 (a 40% increase). The majority of these incidents were classified as type 2: “[v]iolence directed at employees by customers, clients, patients, students, inmates or any others for whom an organization provides services.” 

    A 2011 report by the Emergency Nurses Association, Des Plaines, Ill., revealed that 54.5% of 6,504 nurses polled reported physical and/or verbal violence during their previous workweek. According to these nurses, no action was taken against their attackers in 46.7% of these incidents, and 72% of nurses reported receiving no response from their hospital concerning the violence nurses experienced. Nearly 11% of nurses were blamed for the incident.

    Hospitals must take violence against their employees more seriously, and take safety precautions and protective actions in response to reported instances of violence against nurses.

    Recent media headlines highlight real-life examples. In April 2014, a man was arrested for attempted murder after firing a gun at a doctor in a Daly City, Calif., medical facility. That same week, two nurses were stabbed by patients in separate UCLA hospitals. One incident left the nurse in critical condition after a man bypassed the hospital’s weapon screening area. Another nurse was stabbed in the ear and sustained injuries that were not life-threatening.

    These statistics and media stories were the motivation behind the recent bill passed by the California Legislature. 


    SB-1299 seeks to turn the tide of this violent trend. The bill defines workplace violence as:

    • The use of physical force against a hospital employee by a patient or a person accompanying a patient that results in, or has a high likelihood of resulting in, injury, psychological trauma or stress, regardless of whether the employee sustains an injury
    • An incident involving the use of a firearm or other dangerous weapon, regardless of whether the employee sustains an injury

    Under these definitions, injury is limited to the use of physical force or incidents involving firearms or other dangerous weapons. An injury does not have to actually be sustained to be considered workplace violence. As long as the threat carries a high likelihood of violence, it is covered under the law.

    To prevent such violence, SB-1299 requires all hospital workplace prevention plans to include:

    • Strong training policies for employees regarding how to recognize and respond to violence, and resources for employees who are victims of violence.
    • Comprehensive mechanisms for responding to and investigating incidents of violence and situations involving the risk of violence.
    • Sufficiency of security and staffing, including alarms and emergency responses, with particular attention on facility areas with uncontrolled access, early morning or late night shifts, and employee parking areas.
    • Provisions protecting employees’ rights when they seek help from law enforcement. Hospitals may not retaliate against an employee in any way for seeking assistance.
    • Stringent requirements for hospitals and other medical facilities to report and document violations to California Division of Occupational Safety and Health Administration.

    Because of a California constitutional issue affecting allowable reimbursement, SB-1299 does not apply to hospitals operated by the California Department of State Hospitals, the Department of Developmental Services or the Department of Corrections and Rehabilitation.

    State protections

    Only California, Connecticut, Illinois, New Jersey and Oregon require employer-run workplace violence prevention programs, according to the American Nurses Association. Prevention programs in New York exist but they are limited to public employers. Washington State mandates that incidents of violence be reported. Other states are following California’s lead by enacting legislation aimed at preventing healthcare industry violence, but in a less comprehensive manner1.

    Ensuring compliance

    In crafting policies, employers are free to define workplace violence even more stringently than SB-1299 does. Among other things, policies can prohibit intimidation, stalking, harassment, threats to destroy property, refusal to follow safety procedures, and weapons or dangerous objects on company property.

    Employers should also require mandatory reporting of violations or suspected violations of the workplace violence policy. Hospitals with mandatory reporting policies experience half the rate of physical violence as those without such policies2.

    After ensuring that their written policies are adequate, employers should focus on training. A policy that is not made part of a company’s culture through effective training has limited value. Employers should train all new hires and current employees at least annually on recognizing, reporting and preventing workplace violence. The training should address all requirements of SB-1299, including methods for dealing with angry patients as well as techniques for avoiding conflict escalation. Employees should be informed that workplace violence, as well as failure to report it, can lead to immediate termination with or without prior warning. An at-will policy should also be in place so that employers have more freedom to make termination decisions.

    Supervisors should be trained separately from staff employees. As agents of an employer, supervisors have a higher level of responsibility, and written policies are only as effective as the supervisors charged with enforcing them. Supervisors must know how to recognize potential workplace violence situations early, before they become more serious. The National Institute for Occupational Safety and Health, Washington, D.C., offers a free online workplace violence prevention course to supervisors and employees.  
    SB-1299 also prohibits retaliation against employees for taking action to prevent violence. Retaliation lawsuits have increased exponentially in recent years as employees have become more aware of their rights. Supervisors must understand their responsibility for creating a culture in which employees feel comfortable reporting violence without fear of retaliation.

    Employers should install security cameras in a manner consistent with state privacy laws, ensure they have adequate security staffing, alarms and emergency response plans and pay particular attention to areas with uncontrolled access, early morning or late night shifts, and parking lots.

    While the risk of workplace violence presents challenges, employers can take steps to prepare for SB-1299 and can proactively reduce the risk of harm to their patients, employees and third parties.

    Hertz concurs. “I would encourage practice professionals to conduct a risk assessment regarding their practice and put a plan in place,” he says. “There is no reason to wait until state legislation mandates it. This just makes good business sense.”


    1. Additionally, Arkansas, Alabama, Alaska, Arizona, California, Colorado, Connecticut, Florida, Hawaii, Iowa, Idaho, Illinois, Kansas, Louisiana, Mississippi, Missouri, Montana, North Carolina, Nebraska, New Jersey, New Mexico, Nevada, New York, Ohio, Oklahoma, Rhode Island, Tennessee, Virginia, Vermont, West Virginia and Wyoming have all established penalties for assaults against nurses. Hawaii passed a resolution urging healthcare employers to develop policies and conduct standards that will reduce bullying and workplace violence; Kansas’ law is limited to mental health personnel; Louisiana’s laws apply to emergency department personnel; Mississippi has laws applying to public health personnel; and Ohio authorizes hospitals to post warnings stating that violence against hospital staff will not be tolerated. See Jacobson R, “Epidemic of violence against health care workers plagues hospitals.”

    2. Jacobson R, “Epidemic of violence against health care workers plagues hospitals.”

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