An APSI White Paper

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3100 Beacon Boulevard West Sacramento, California 95691

Hospital Security Overview

By FIN M JOHNSON, Vice President / COO, APSI fjohnson@ahtna.net MARGARET A MELBERG, Director of Operations, APSI mmelberg@ahtna.net

August 22, 2012 April 25, 2013 R1

Contents
Introduction Problem Statement Hotel Specific Violence Issues Workplace Violence Practical Solutions Summary 2 2 3 6 8 9

Introduction This report is a brief overview of security as it relates to the healthcare industry, focused on hospitals, patients, staff and others who frequent the establishments. Solutions are dependent on the choices, risk tolerance and other analysis necessary to define the desired solutions. Problem Statement How does a hospital or group of hospitals and facilities under a single management structure provide and support consistent and trustworthy security services while maintaining the open and positive atmosphere needed to provide those services?

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The past decade has produced a significant body of work concerning security in the health care industry. Governmental sources as well as the industry itself have produced dozens of scholarly and business-related treatises on the subject. We researched and brought here a small sampling of the most consistent and recent data combined with our experience on the relevant issues. HOSPITAL SPECIFIC VIOLENCE ISSUES: Snapshot of Violence in Hospitals Nationwide1 - Between May 2009 and February 2010 (10 months) o 97.1% of physical violence was perpetrated by patients and / or relatives. o 80.6% of physical violence occurred in patients rooms 23.2% in corridors, hallways, stairs, or elevators 14.7% at nurses stations o 38.2% of physical violence against emergency nurses occurred while triaging patients 33.8% while restraining or subduing patients 30.9% while performing invasive procedures o 15% of male nurse report being victims of physical violence compared to 10% of female nurses According to the Bureau of Labor Statistics (BLS) 2,637 assaults on hospital workers occurred in 1999 8.3 assaults per 10,000 workers. The rate for all private-sector industries that same year was 2 per 10,000.2

There is currently no national standard or [single, agreed upon] guideline for hospital security, so safety measures differ from hospital to hospital with some relying on armed guards and metal detectors and others using unarmed guards and security cameras. Homeland Security News, 2012

The reference data and actual accounts are abundant on the subject of hospital security. On September 3, 2010, Darrell Garner entered the room of his son at the Baton Rouge Medical Center. In the room was Garners estranged wife and her boyfriend. Garner shot both his wife and the boyfriend. Although police were called, Garner walked out while physicians and nurses treated the victims. He turned himself in over a week later. A retired teacher upset about the death of his mother at a Georgia hospital brought a weapon to the facility and killed three people. A man whose daughter was involved in a fight at a North Carolina nightclub followed the alleged assailant and her boyfriend to a hospital emergency room and shot them both. An 85-year-old man being treated in a cardiac unit at Danbury Hospital shot a nurse three times and was shot with his own gun while being subdued.3

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Emergency Department Violence Surveillance Study, Emergency Nurses Association; 2010 NIOSH (CDC) publication No. 2002-101; April 2002 www.cdc.gov/niosh 3 http://www.newstimes.com/news/article/Hospital-violence-becoming-an-epidemic-security-427025.php

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Following the Danbury event, the Occupational Safety and Health Administration (OSHA) cited that health care facility for violenceprevention deficiencies. New strategies in place at Danbury have had a significant impact on incidents. A mix of physical and mechanical security measures combined with training and awareness have resulted in a 75 percent drop in reported incidents [with] nine out of 10 conflicts resolved at the bedside through discussion.4 NIOSH5 reports other prevention strategies that have worked: - Security screening at an urban hospital in Detroit prevented the entry of 33 handguns, over 1,300 knives and nearly 100 mace / pepper-spray canisters in a 6-month period. - A violence reporting program in Portland, Oregon VA medical center identifies patient with a history of violence. The program helped reduce the number of violent attacks by 91.6% by alerting staff when serving these patients. - In New York, a program to use ID badges and color-coded passes to limit visitors and restricting movement in the facility reduced the number of reported violent crime by 65%. Chart 2 shows that Health Care and Social Assistance workers from 2003 to 2007 accounted for over 50% of the assault victims as compared to all private-sector industries. Nearly three-quarters (75%) of these assaults were perpetrated by patients or care facility residents.6

4 5

Whitney, L.J. Howell, Hospital & Health Networks, Violence in Hospitals, January 2011 NIOSH is the research agency of the Center for Disease Control (CDC) 6 Janocha, Jill A., Smith, Ryan T., U.S. Bureau of Labor Statistics, Workplace Safety and Health in the Health Care and Social Assistance Industry, 2003-07, August 20, 2010.

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On June 3, 2010, the Joint Commission7 released a Sentinel Event Alert noting a significant increase in reports of assault, rape, and homicide, with the greatest number of reports in the last three years. The commission continued to report: for many reasons, in particular high-traffic areas coupled with high-stress levels the Emergency Department is typically the hardest area to secure, followed by general medical / surgical patient rooms. 8 The Joint Commissions database found six recurring caused* for these criminal events: 1) Issues in leadership were noted in 62% of the events, most notably problems in the areas of policy and procedure development and implementation. 2) Human resources-related factors were noted in 60% of the events, such as the increased need for staff education and competency assessment processes. 3) Assessment issues, noted in 58% of events, particularly in the areas of flawed patient observation protocols, inadequate assessment tools, and lack of psychiatric assessment. 4) Communication failures, noted in 53% of events, in terms of deficiencies in general safety of environment and security procedures and practices. 5) Physical environment issues noted in 36% of the events, in terms of deficiencies in general safety of the environment and security procedures and practices. 6) Problems in care planning, information management and patient education were other causal factors identified less frequently. The commission suggests that hospitals take the following actions minimize violent incidents:9
* APSI has some disagreement with this list inasmuch as the actual causal events and or systemic root-cause for behavior leading to the event is negated in the analysis. CRIME CONTROL including workplace violence has to take into account the behavioral aspects of the offender and the protection of victims.

Work with the security department to audit your facility's risk of violence. Evaluate environmental and administrative controls throughout the campus, review records and statistics of crime rates in the area surrounding the healthcare facility, and survey employees on their perceptions of risk. Identify strengths and weaknesses and make improvements to the facility's violence-prevention program. Take extra security precautions in the Emergency Department, especially if the facility is in an area with a high crime rate or gang activity, such as having uniformed security officers, and limiting or screening visitors for weapons. Make sure the HR department prescreens job applicants and for clinical staff, and verifies the clinician's record with appropriate boards of registration. If an organization has access to the National Practitioner Data Bank or the Healthcare

An independent, not-for-profit organization, The Joint Commission accredits and certifies more than 19,000 health care organizations and programs in the United States. 8 Clark, Cheryl. Health Leaders Media, Healthcare Violence is Increasing; Is Your Hospital Prepared? , June 4, 2010. 9 Ibid, Clark

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Integrity and Protection Data Bank, check the clinician's information, which includes professional competence and conduct. Confirm that the HR department ensures that procedures for disciplining and firing employees minimize the chance of provoking a violent reaction. Require appropriate staff members to undergo training in how to respond to agitated, potentially violent family members and include procedures for notifying supervisors and security staff. Ensure that notification procedures or code activations are in place and that employees are properly trained in their use. Encourage employees and other staff to report incidents or threats of violent activity. Train supervisors to recognize when an employee or patient is exhibiting behaviors related to domestic violence issues. Ensure that counseling programs for employees who become victims of workplace crime or violence are in place. If a violent act does take place, report APSI concurs with the commissions the crime to law enforcement, recommendations; however, the assessments, planning, resourcing and implementation recommend counseling and support to must be done in a professional, effective and patients and visitors affected, review cost efficient manner. the event and make changes to prevent occurrences.

WORKPLACE VIOLENCE Violence in the hospital or health care setting is a sub-set of the greater issue of workplace violence. As shown, hospital or health care violence bears an unequal and elevated percentage of the violence when compared to private-sector employees. In an unprecedented departure from their norm, the Center for Disease Control (CDC) has declared workplace violence as an EPIDEMIC. Citing over 100,000 workplace violence incidents per year and workplace homicides at 750 to 1000 per year, the CDC has fully engaged in the workplace violence prevention arena. Top reasons to have a workplace violence program: - Safety of employees & patients - Limit exposure to litigation - A dedicated and supported full-spectrum security program will dissuade would-be workplace violence suspects. BJA statistics10: Each year - Nearly 1 million individuals are victims of violent crime while working. - 1.8 million work-days lost - Average loss to business = $36 billion Average cost of a single workplace homicide11 = $800,000
10

U.S. Bureau of Justice Administration

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The National Crime Prevention Council suggests these basic steps toward workplace violence: - Zero-tolerance policies toward ALL workplace violence and harassment
o Pre-employment statements, Collective Bargaining Agreement clauses, Annual evaluation questionnaire / statements

Allocate sufficient resources to detection, protection, training, response, mitigation and recovery Develop a system of accountability Provide medical & psychological counseling* Study trends & implement security measures Provide training and educational programs.
*Post-traumatic Stress Disorder / Critical Incident Stress Management

ASIS / CRISP Report -- Preventing Gun Violence in the Workplace

The term active shooter has become linked to workplace violence because those shootings receive press coverage more than the other workplace violence incidents or nonhomicide incidents. However, most incidents of violence are similar in time and duration, whether or not a homicide occurs. Regardless, the most popular answer to the question what would you do? remains, Call 9-1-1 The facts about police response: Most active shooter or workplace violence incidents are over or well underway in 3 minutes. The average emergency response for a single police officer (in California) is 3 to 5 minutes.
o
FBI Publication Workplace Violence; Issues in Response

In cases where an active shooter is reported, the common police response dictates a first3 or first-5 where that number of officers assembles prior to engaging the threat. That can take much more time depending on the jurisdiction, police staffing, mutual aid ability, and call volume.

The average SWAT12 team (if one is available) can be on-scene and prepared to engage the threat in 30 to 45 minutes. In the last 12 years, how many active shooter events (hospitals, schools, churches, et cetera) have been ended by an on-duty police officer dispatched13 to the scene? - None.14 Employees need to be prepared to react to workplace violence.
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National Institute for Occupational Safety and Health Special Weapons and Tactics; many jurisdictions have eliminated SWAT in recent budget cuts. 13 There are some incidents wherein a police officer was at the scene and reacted to save lives and terminate the threat; however, not dispatched to a 9-1-1 call for assistance. 14 http://www.ileese.org/Immediate%20Response%20Oct.ppt#333,11,Slide 11

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Some Practical Solutions: The following is a short list of ideas and potential solutions but is in noway an exhaustive listing of all the solutions available; especially given the magnitude of the business type, number of facilities, personnel, clients / patients, and locations.

Enterprise Security Solutions is the joining of all business units in a systematic, holistic approach to security issues; and, is the foundation for collaborative corporate-wide riskbased security measures. Enterprise Security includes all security functions, plus the security component of all business functions from Senior Management, Human Resources, Administration, Finance, and Operations. The level of implementation can be adjusted depending on the need, usually based on board-level risk and the analysis of all factors involved in security, public safety and requirements of the individual facility. A realistic and professional risk assessment focused on security issues, using direction of senior management, will detail the vulnerabilities, criticalities and threats. Once this is known, security measures are tailored to move the risk to an acceptable level. CPTED CRIME PREVENTION THROUGH ENVIRONMENTAL DESIGN is an industry standard approach to secure a facility while taking into account the accessibility and function of the space. CPTED includes all physical, mechanical and electronic measures taken in concert to achieve the level of security needed. The layers or factors designed into the security system can seamlessly increase security to some locations while allowing controlled access to others. Often mistakenly thought of as just planters and barricades, CPTED includes psychological and physiological influences as well. For instance, it is a well-tested assertion that a person seeing they are on camera (seeing their own image on a video monitor) whether recorded or not will conduct themselves in a manner commensurate to their location. Layered Security Measures Any single security measure (lock, card key, security officer, gate, fence or door) has a chance of failure or the ability to be defeated. When a second layer or factor is added, the chance of failure or defeat is decreased exponentially. As the number of layers or factors increase as with cyber security the reliable security posture increases. For example, key card access prohibits most unauthorized persons from entering a doorway. A key card system with keypad and personal pin requirement (two factors) limits more nearly 90%. A man-trap (anti-piggy-backing device or single entry doors) almost eliminates the ability for an unauthorized person to enter (99%). Add in another factor surveillance or security personnel and 100% can be achieved. A building or facility can be layered to allow increasing or decreasing access protocols throughout. Open access lobby (as with normal hospital lobbies) can lead to a limitedaccess vestibule for patient check-in, relative waiting areas or other limited access needs. This room can lead to a more secure area which, in turn, leads to a secure area where access to non-employees is very limited and constantly monitored.

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Liaison with Local Law Enforcement The need to have a quality relationship with local law enforcement cannot be over emphasizes. The CEO and Senior leadership should, no less than annually, meet with police chiefs and sheriffs in their jurisdictions to exchanges ideas, incidents, lessons learned and future needs. Likewise, the management staff, especially security managers, should have an open and active relationship with the supervisors and managers at the local law enforcement agencies. Table-top and actual scenario training exercises should be conducted with all the local emergency service providers on a regular basis. Advanced Electronic Monitoring Advancements in monitoring and security surveillance over the past decade has eliminated many of the reasons businesses refrained from the use. Advanced Radio Frequency (RF) badges with tracking ability, low cost visitor badges with the same functionality, local and remote monitoring ability and other refinements are available at a fraction of their price from just 5-years ago. As an example, our experiences include using military grade analytical software and hardware allow for a full spectrum of choices. From heatsensing to infrared and radar tracking of suspects, cameras and accessories have gone far beyond the grainy black & white images from just a few years ago. Systems like the iGuard (photo) provide real-time, full color and extreme zoom capabilities to a 24-hour staffed security center. Strobe lights, sirens, microphones and speakers allow for remote security staff to manage incidents, notify responders, record incidents; all for a fraction of the cost of a full-time security officer. A single monitoring officer at a remote location can manage up to 40 cameras during a normal shift. The software assists by locating anomalies in the field of view not pixel changes as with older software. The limits and ability of this system can be adjusted to meet the requirements of local, state and federal regulations for surveillance use. Other smaller even invisible surveillance methods greatly assist in limiting litigation and exposure to suits, complaints, and accusations. Summary: This issue of security provision is multi-faceted in the smallest of industries. Proper planning can limit the wasteful spending and will dramatically increase the potential of success in the provision of security. Training, communication, sound policy and procedure, coupled with oversight and enforcement, will offer the best solution to security needs. Based on a practical foundation of need, risk appetite, and available resources, the security decisions can greatly increase comfort of staff and patients while assisting in liability and litigation avoidance.

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