On November 28, the Quality, Safety & Oversight Group of the Centers for Medicare and Medicaid Services (CMS) urged healthcare industry leaders to take steps to protect healthcare workers from workplace violence. Recommended steps to prevent workplace violence in hospitals include ensuring workers receive adequate training, having sufficient staffing levels, providing ongoing assessment of patients and residents for aggressive behavior and indicators, and appropriately adapting patients’ or residents’ care interventions and environment.

CMS provides healthcare reimbursements under Medicare and Medicaid and sets certain requirements for the healthcare industry. Quality standards for patient care can overlap with worker health and safety requirements.

To provide care in a safe setting for both patients and healthcare workers, hospitals need to identify patients at risk for intentional harm to themselves or others, CMS recommended in its November 28 memo, as well as identify environmental safety risks for such patients and provide education and training for staff and volunteers. CMS said it expects hospitals to demonstrate how they identify patients at risk of self-harm or harm to others and what steps they are taking to minimize those risks.

Risks for self-harm, which may also harm others, include access to medications, accessible light fixtures, bell cords, breakable windows, harmful substances, ligatures, plastic bags that may suffocate, oxygen tubing, and sharps.

Under CMS hospital emergency preparedness regulations, hospitals must develop and implement an emergency preparedness plan based on community- and facility-based risk assessments, utilizing an all-hazards approach. Emergency preparedness plans must include strategies for addressing emergency events, including patient population risks.

Hospital worker training should cover the identification of patients at risk for harm to themselves or others, the identification of environmental patient safety risk factors, and mitigation strategies.

Incidents cited by CMS in its memo included patient deaths, as well as a nurse who was sexually assaulted by a behavioral health patient in a unit without adequate staffing. The assailant was stopped through intervention by other patients. CMS characterized the incidents as examples of systemic failures placing both patients and staff at risk.

CMS has regulatory oversight of the administration and operations of hospitals and other healthcare providers that receive Medicare and Medicaid funds. The U.S. Occupational Safety and Health Administration oversees employers’ compliance with workplace health and safety standards and the Occupational Safety and Health Act of 1970.

There is no current federal workplace violence standard, and OSHA currently cites employers under the General Duty Clause of the Occupational Safety and Health (OSH) Act (§5(a)(1)). The agency has a rulemaking in the prerule stage for a federal workplace violence standard for health care and social assistance. OSHA issued a request for information for the rulemaking in the final weeks of the Obama administration, and this spring, the agency revealed plans for a Small Business Regulatory Enforcement Fairness Act (SBREFA) review of the rulemaking.

In 2016, the agency issued voluntary guidelines for preventing workplace violence for healthcare and social service workers. The recommended elements of an effective workplace violence prevention program include management commitment and employee participation, worksite hazard analysis, hazard prevention and control methods, safety and health training, and recordkeeping and program evaluation.

Last year, the Joint Commission, which oversees the accreditation of hospitals and other healthcare facilities, issued newly revised workplace violence standards. Healthcare providers that receive Medicare, Medicaid, and private insurance reimbursements must be accredited by the Joint Commission or other independent organizations. Requirements of the Joint Commission standard include managing safety and security risks through an annual worksite analysis, monitoring conditions in the facility’s environment, collecting information on facility conditions, and providing ongoing staff education and training.

Under the Joint Commission standard, hospital leaders must develop and implement policies and procedures to prevent and respond to workplace violence, a process for reporting incidents to analyze incidents and trends, and a process for follow-up and support for victims and witnesses affected by workplace violence, such as trauma and psychological counseling.