The Joint Commission Workplace Violence Requirements

The Joint Commission recognizes that workplace violence in health care settings has increased in incidence over the past decade. According to the US Bureau of Labor Statistics, health care and social services personnel are five times more likely to experience workplace violence than staff in other occupations. On top of this, the COVID-19 pandemic and widespread political polarization over vaccines, mask mandates, and other issues have exacerbated the risk of conflict and violence in health care facilities. Given the rising concerns, The Joint Commission rolled out new workplace violence prevention requirements, effective January 1, 2022. 

The Center for Personal Protection and Safety (CPPS) is a leading developer and provider of customized training solutions. Partnering with clients, CPPS empowers individuals to be stakeholders in their personal safety and security. It’s clear that workplace violence can be a complex topic that requires a training roadmap to ensure full compliance with standards. But as a leader in workplace violence prevention training, CPPS can provide guidance and training to any Joint Commission-accredited hospital and critical access hospital to ensure compliance with the newly released requirements as follows:

1) EC.02.01.01, EP 17 (new): The [organization] conducts an annual worksite analysis related to its workplace violence prevention (WPV) program. The [organization] takes actions to mitigate or resolve the WPV safety and security risks based upon findings from the analysis.

CPPS offers a two-day WPV vulnerability assessment that helps identify potentially harmful situations and recommends preventative measures to reduce the risk of violence. Throughout the process, recommendations are made to bring systems and structure to portions of a security program that may have previously been managed informally.

2) EC.04.01.01, EP 1: The [organization] establishes a process(es) for continually monitoring, internally reporting, and investigating the following: Safety and security incidents involving patients, staff, or others within its facilities, including those related to workplace violence.

CPPS assists with the creation of Contingency Plans that outline procedures to follow during actual incidents, to include operational checklists, emergency contact lists, notification schedules, and resource lists. As part of a WPV  prevention program, it’s important to establish a “Threat Assessment/ Management Specific” centralized record keeping protocol, knowing that traditional HR systems will not be adequate to respond to WPV specifics once the program is fully mature. A centralized record keeping system can help eliminate information silos.

3) EC.04.01.01, EP 6: Based on its process(es), the [organization] reports and investigates the following: Safety and security incidents involving patients, staff, or others within its facilities, including those related to workplace violence.

CPPS recommends a WPV prevention program that includes an interdisciplinary Threat Management Team (TMT) that is trained to respond to reports of troubling behavior and/or actual violent threats or incidents. Creating and training a TMT will serve to ensure that clear lines of responsibility, authority, and a general incident management process are established before a threat or violent incident occurs.

4) HR.01.05.03, EP 29 (new): As part of its workplace violence prevention program, the [organization] provides training, education, and resources (at time of hire, annually, and whenever changes occur regarding the workplace violence prevention program) to leadership, staff, and licensed practitioners. The [organization] determines what aspects of training are appropriate for individuals based on their roles and responsibilities. The training, education, and resources address intervention, recognition, response, and reporting of workplace violence as follows:

• What constitutes workplace violence

• Education on the roles and responsibilities of leadership, clinical staff, security personnel, 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

CPPS offers a five-tiered approach to training as follows:

Tier 2—Awareness:  Even though extreme violence is growing in frequency; workplace aggression is more prevalent and can be extremely damaging. For that reason, training employees in non-violent response and conflict resolution assists in reducing the risk that volatile situations will escalate to physical violence. For the general employee populace, the primary concern is establishing which behaviors are considered unacceptable. Training includes both behavioral and psychological aspects of workplace violence and associated risk factors; reporting responsibilities and venues; reportable problematic behavior; impact of domestic violence on the workplace; and response to emergency situations.

Tier 3 – Managers/Supervisors: Its important managers and supervisors augment their current understanding of workplace violence prevention. Enhanced training for managers and supervisors should include trend insights for preventing workplace violence; Behaviors of Concern; de-escalation techniques; safe layoffs, suspensions, and terminations; perspectives and insights on active shooters; internal and external dangers, early warning signs, and prevention strategies.

Tier 4 – Threat Management /Crisis Management Team(s):  Members of the Threat Management Team should receive the most detailed and comprehensive training regarding behavioral and psychological aspects of workplace violence, violence risk screening, investigatory and intervention techniques, incident resolution, and case management strategies.

Tier 5 – Executive Team:  Training consists of a simulated disaster (such as an active shooter) tailored to the organization using a tabletop exercise and/or an Executive Briefing, with group discussion to navigate through potential challenges a crisis exposes.

5) LD.03.01.01, EP 9 (new): The [organization] has a workplace violence prevention program led by a designated individual and developed by a multidisciplinary team that includes the following:

• Policies and procedures to prevent and respond to workplace violence

• A process to report incidents in order to analyze incidents and trends

• A process for follow-up and support to victims and witnesses affected by workplace violence, including trauma and psychological counseling, if necessary

• Reporting of workplace violence incidents to the governing body

CPPS recommends formalizing a WPV Prevention Program that is communicated to employees at their time of hire and throughout their course of employment. The program should:

• Clearly define unacceptable behavior;

• Regulate or prohibit weapons on-site and during work-related activities;

• Require the prompt reporting of suspected policy violations and any circumstances that raise a concern for safety from violence;

• Provide multiple avenues for reporting;

• Assure employees that reports are treated with the highest degree of discretion and promptly investigated;

• Include a commitment to non-retaliation toward employees who make a good faith report;

• Impose discipline for policy violations, as appropriate, up to and including termination; and

• Require or encourage employees to inform clearly identified personnel of any "protective or restraining" order they have been awarded, especially if the order lists the workplace as a protected area.

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