Get Ready! Effective January 1, 2022, new TJC Workplace Violence Prevention Requirements go into effect. They apply to all TJC accredited hospitals.

Currently, the requirements don’t apply to organizations accredited under the Behavioral Health Care standards. However, we recommend these organizations also review the new requirements to see what best practices they may want to adopt.

Background

The New TJC Workplace Violence Prevention Requirements address a critical issue in the healthcare industry. The incidence of violence–related injuries to healthcare workers has steadily increased for a decade.

In 2018, healthcare and social service workers were five times more likely to experience workplace violence than all other workers. Moreover, the rate of injury to workers in psychiatric and substance abuse facilities is significantly higher than in other healthcare settings.

TJC Workplace Violence Prevention Standards: What’s Required?

TJC defines workplace violence as “An act or threat occurring at the workplace that can include any of the following: verbal, nonverbal, written, or physical aggression; threatening, intimidating, harassing, or humiliating words or actions; bullying, sabotage; sexual harassment; physical assaults; or other behaviors of concern involving staff, licensed practitioners, patients, or visitors.”

The new standards are embedded in three chapters of the 2022 Hospital Accreditation Manual: Environment of Care, Human Resources, and Leadership. So, let’s review the key requirements in each chapter.

Environment of Care Chapter

There’s a new requirement at EC.02.01.01 Element of Performance (EP) # 17. First, the organization must conduct an annual worksite analysis related to its workplace violence prevention program.

So, what should you include in this analysis? TJC is fairly specific about this. You must include:

• A proactive analysis of the worksite
• An investigation of the hospital’s workplace violence prevention incidents
• An analysis of how the program’s policies, training, education, and environmental design reflect best practices and conform to applicable laws and regulations.

The International Association for Healthcare Security and Safety Foundation (IAHSS) has an excellent resource on this topic. It’s titled Threat Assessment Strategies to Mitigate Violence in Healthcare and includes a section on the components of a threat assessment.

Once you’ve completed the worksite analysis, you must act on the results. Specifically, you’ll need an action plan to address the workplace violence risks you identified in your analysis.

Human Resources Chapter

TJC has added a new training requirement to the Human Resources chapter: HR.01.05.03 EP 29. It requires training at time of hire and annually. This applies to both staff and licensed independent practitioners.

The training must cover:

• What constitutes workplace violence
• Education on the responsibilities of leadership, clinical staff, security, and external law enforcement
• Training in de-escalation, nonphysical intervention skills, physical intervention techniques, and response to emergency incidents
• The reporting process for workplace violence incidents

Leadership Chapter

Last, TJC has added a new requirement to the leadership standard on maintaining a culture of safety and quality:  LD.03.01.01 EP 9. It requires a designated leader for the workplace violence prevention program. Furthermore, it requires a multi-disciplinary team to develop the program.

In addition, there must be data collection and analysis of workplace violence incidents through your Quality Assurance/Performance Improvement process. Lastly, you must report this data to your governing body.

Survey Readiness: What to Do Now

First, carefully review these new requirements with your leadership team. Likewise, check out the many resources available on TJC’s Workplace Violence Prevention Portal.

Next, designate a leader to head up your workplace violence prevention program.

Then, identify the multi-disciplinary team that will lead this effort. That could be an existing committee such as your Safety Committee. Or, it could be a team convened specifically to work on this initiative.

At the same time, have your Human Resources and Education/Training Departments develop the training modules required by these new standards.

Barrins & Associates Resources

Now that TJC is back to “business as usual” we are, likewise, busy conducting Mock Surveys and Continuous Readiness Consultations. We’ve incorporated these new TJC Workplace Violence Prevention standards into our tools and templates. As always, we’re prepared to support your ongoing survey readiness and best practices for regulatory compliance.