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NORTHERN COCHISE COMMUNITY HOSPITAL
VIOLENCE PREVENTION POLICY/PROCEDURE
DEPARTMENT: Safety
SUBJECT: Violence Prevention
Reviewed By:
| Review Date:
| Committee
| 07/20/17
| Med Staff
| 08/28/17
| Governing Board
| 09/26/17
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REFERENCES: OSHA Guidelines, CMS Guidelines, American Society for Healthcare Risk Management, and the Crisis Prevention Institute.
SCOPE: All Hospital Staff.
POLICY: Mitigation impact of violent behavior and acts on our patients, visitors, and staff.
PROCEDURE:
Prevention Measures
1. Threat Management Team (TMT)
- Threat management program will provide immediate support to staff when they observe or are involved in a situation with a patient, family member or visitor, behavior that has the potential to escalate beyond their control.
- Training and skills development for all staff to proactively intervene to prevent escalation and the skills to de-escalate potential volatile situations if they do occur.
- Threat Management Team will be initially made up of select who have received special training in de-escalation of potential volatile situations, such as CPI (Crisis Prevention Institute) training, and/or Senior Leadership.
- Long term goals will be for all staff who interact with patients, family, and guests to have a basic level of training.
2. Warning Signs and Behavior
- May be noted in the EMR on the patient.
- If a patient or a family member/guest becomes overly aggressive, they will be inserted into the patient's EMR for review by Nursing Administration and Threat Management Team.
- Threat Management Team or staff trained in de-escalation skills should be involved when patients/family or guests become:
Contextually inappropriate and make verbal threats.
Contextually inappropriate with physical contact/assault and battery.
- In rare cases the visitors/family members/patients may be issued a trespass warning, and not allowed on property unless seeking emergency medical treatment only.
- Threat Management Team should also be informed on cases of staff whom may face domestic violence threats. If actual physical violence has occurred, stalking/harassing behavior, orders of protection and other related activity, that may cause actions to carry over onto NCCH property.
3. Education and Training
- Threat management team will conduct regular training in Violence Prevention, as required by OSHA and CMS codes. Threat Management Team is largely the Management team responding to Emergency Code Green (Patient Out-Of-Control), activation in NCCH.
- Training on aggressive Behavior De-escalation will be a continual process for staff.
- Patient & Visitor handbook/policy updated to address threatening behavior and ramifications.
- Threat Management Team will periodically review Security & Safety technology and equipment.
SAFE-POL-004
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