At the Crisis Prevention Institute (CPI), we are passionate about promoting everyone’s safety. CPI is committed to creating safe work environments across the US. California’s proposed state standards include significant improvements to training, documentation, and post-incident response provisions. CPI continues to emphasize that staff training is essential for a safe and effective work environment.
Below, you’ll find the public comment letter we wrote to the Occupational Safety and Health Standards Board to share our subject matter expertise on workplace violence prevention policies and procedures in health care.

Comment Letter Provided to
Sarah Money, Occupational Safety and Health Standards Board
2520 Venture Oaks Way, Suite 350
Sacramento, CA 95833

December 16, 2015
Re: Proposed State Standard, Title 8, Chapter 4, Section 3342
To whom it may concern,
The Crisis Prevention Institute, Inc. (CPI) would like to thank the Board for the opportunity to provide public comment on the Proposed State Standard, Title 8, Chapter 4, Section 3342: Workplace Violence Prevention in Health Care.
Too often we see serious injuries occurring in health care that are a result of the facility’s lack of commitment to equipping staff with the skills and strategies for recognizing, preventing, and managing the various forms of workplace violence they are faced with every day.
Our 35 years in business has shown us that while it is difficult to “engineer out” the greatest risk in health care, being a victim of workplace violence, it is not difficult to equip staff with proven strategies for preventing, managing, and diminishing the impact of those risks.
CPI applauds the Occupational Safety and Health Standards Board for undertaking the difficult task of crafting new standards dealing with workplace violence prevention in health care.
With that said, CPI would offer a few specific recommendations to the policy to help ensure that staff have the safest workplace possible:

Section (b) Definitions

1. Under section (b) Definitions, we appreciate your definition of “patient specific risk factors” to include not only psychiatric diagnoses, but also the presence of “any condition or disease process that would cause confusion and/or disorientation or history of violence, which may increase the likelihood or severity of a workplace violence incident.” We cannot tell you how often we hear from health facilities that “we do not have behavioral health” as if to mean that only those patients with a psychiatric diagnosis are capable of violence in health care.
2. Also under section (b) Definitions, we appreciate the expansive definition of “work practice controls.” The most comprehensive workplace violence prevention solutions include a combination of strong policy and procedures to support training and vice versa. Too often we see health care entities cutting corners on one aspect or another (e.g., a solid policy but not training; solid training but no guiding procedures for managing incidents; policies/procedures or training that cannot be implemented because of staff levels).
3. Also under section (b) Definitions, we applaud the comprehensive definition of “workplace violence.” We encourage the Board to write into the standard that considerations should be given to those training organizations that can support a health facility with training to mitigate the risks associated with all workplace violence types outlined in this definition. For example, at CPI we train staff in de-escalation, prevention, disengagement strategies, debriefing, and physical restraint techniques, but also have modules in workplace bullying and domestic violence and its impact on the workplace.

Section (c) Workplace Violence Prevention Plan

1. We appreciate the thoroughness of the elements of the Workplace Violence Prevention Plan outlined in section (c). Of special note is the application of the plan to all employees in the health facility. Preventing workplace violence is everyone’s responsibility. Any one employee may recognize the early warning signs of potential violence or may be first on the scene of an escalating situation; extending the requirements of training under the plan to these individuals is critical.
2. Additionally, we appreciate the requirements for documentation/reporting as well as the details specifically supporting the reporting and investigation of Type 3 Violence. Despite the Joint Commission Leadership Standard Addressing Disruptive and Inappropriate Behaviors (effective January 2009) which holds similar requirements to this Board’s recommendations, we regularly find that health facilities are not addressing the issue of employee-to-employee workplace violence.
3. In section (9) under (c) Workplace Violence Prevention Plan, CPI supports the procedures for identifying and evaluating patient-specific risk factors, and the assessing of visitors. We do caution, however, the labeling of patients or visitors solely based on historical data. Additionally, we caution that employees be trained to use “universal precautions” for workplace violence just as they do for other identified risks in health facilities. Even with consistent assessment and evaluation, an individual’s (patient or visitor) mental status or medical status can change quickly, and staff should always be prepared to respond.
4. In section (10) (A), CPI appreciates the clarification regarding what it means for a staff member to be “available” to respond to workplace violence. Too often, staffing levels meet minimum requirements, but do not afford the ability of individuals to respond to crisis due to their other duties.
5. CPI is in full support of the post-incident response and investigation provisions outlined in section (11). We would recommend adding training in the process for debriefing incidents to the required initial and ongoing training for staff outlined in section (f) Training in sections (1)(A), (2), and (3).
Debriefing should take place with the individual who was in crisis whenever possible, and also all team members who were present at the crisis. This process gives the team who responded the opportunity to identify what worked well to manage the situation, but also to identify where early warning signs may have been missed, where de-escalation strategies may have been ineffective, and to make a plan for addressing future situations of this type. This debriefing also helps the organization identify training gaps in teams and individuals to help customize their ongoing training process.

Section (e) Annual Review of the Workplace Violence Prevention Plan

Policy review is a necessary part of every ongoing training process. Employee involvement is imperative in this process. Too often policies are developed and cascaded down within the organization to direct care providers without their input. This creates situations where it is impossible to follow or implement policies and procedures because critical details of daily practice were overlooked by those not providing the care.

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Section (f) Training

1. CPI respectfully requests the Board to consider adding the following language either in the opening paragraph in the training section or within section (1), (2), and (3): “provide effective training from a nationally recognized, evidence-based, training provider to all employees.”
We make this request for a couple of reasons. First, there are many training programs out there that are not grounded in evidence of effectiveness. There are many health facilities who choose to develop their own training but do not have the expertise or the systems in place for maintaining the training program to ensure it is consistent with best practices. Second, both The Joint Commission Elements of Performance for Behavioral Health and the CMS Hospital Conditions of Participation for Patients’ Rights use this language when they speak about required training. This would create consistency between CA OSHA, The Joint Commission, and CMS conditions for participation.
2. CPI supports the differentiation in the levels of training required for different employees within a health facility. We believe that everyone in a health facility should have an awareness and understanding of the policies and procedures for reporting, documenting, and responding to incidents of workplace violence.
Additionally, we believe that all staff should have at least an awareness of how to recognize the early warning signs of potential violence and how to activate a crisis response team. CPI encourages each facility to do a risk stratification of the employees’ roles and responsibilities along with a risk stratification of the varying areas of the hospital to create a comprehensive training process that addresses all the levels of training outlined in this section.
3. CPI supports the concept of annual refresher training as outlined in section (f) (2). We further support the high level of customization the Board is recommending so that all concepts can be applied to the employees’ daily practices in a meaningful way. This will aid in learning transfer.

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4. CPI supports the elements outlined in section (f) (3) for those employees working in the highest risk areas or responding as part of their duties to high-risk situations in the health facility. As noted earlier in this letter, CPI recommends adding training in debriefing strategies to the elements required for training in this section.

Section (g) Reporting Requirements and (h) Recordkeeping

CPI supports the requirements under these two sections. A facility can only change what they measure. Too often these incidents are not reported or recorded, leaving the impression that exposure to workplace violence is simply “part of the job.” The truth is that there are a number of ways to prevent incidents from escalating to the point at which they create emergencies as outlined in section (b) Definitions. Staff who have been trained and provided with opportunities for re-training, practices, and drills will approach a potential violent situation much sooner, and with more confidence than staff who are untrained.
CPI believes that the Occupational Safety and Health Standards Board has incorporated many of the most important considerations within the proposed standard that have proven to result in a successful adoption as seen in other, similar standards.
In fact, many of the inclusions such as documentation requirements, an annual refresher training requirement, and post-incident response provisions are important and sometimes overlooked elements in a standard such as this. We understand how challenging the drafting of a standard like this is and commend the Board for its efforts.
We appreciate the opportunity to comment on this important standard and hope that you find these recommendations helpful. Should you have any further questions, or have an interest in discussing the recommendations, I would encourage you to contact me via phone at 414.979.7129 or by email.
Daniel Gugala
General Counsel
Crisis Prevention Institute

Additional resources

If you’d like to see more of our recommendations, or to research pending and passed legislation in your state, browse our Legislation section. Also check out our Advocacy posts, read about restraint reduction and CPI training, and get details about Nonviolent Crisis Intervention® training.