April 6, 2017
OSHA Docket Office, Docket No. OSHA–2016–0014
Technical Data Center, Room N–3653
OSHA, U.S. Department of Labor
200 Constitution Ave., NW
Washington, DC 20210;
Re: Docket No. OSHA–2016–0014
To Whom It May Concern:
The American College of Occupational and Environmental Medicine (ACOEM) is pleased to respond to OSHA’s request for information regarding a proposed rule to prevent workplace violence in health care and social service settings. ACOEM is the pre-eminent national organization of occupational medicine physicians and other health care professionals who champion the health of workers, workplaces, and community environments. The ACOEM Section on Medical Center Occupational Health (MCOH) focuses specifically on occupational risks in health care settings.
ACOEM agrees that an OSHA standard would likely be very helpful in preventing episodes of violence to workers in high-risk settings, including hospitals, other mental health facilities, and social service settings, and salutes OSHA for starting a rule-making process. ACOEM recognizes that prior OSHA standards specifically intended to improve healthcare workplace safety, such as the Bloodborne Pathogen Standard, have been highly effective in driving improvement. ACOEM further believes that it is time to progress from guidance, such as the guidance document for preventing workplace violence in healthcare and social service settings (OSHA publication 3148, 2015), to a stronger mechanism for enforcement. Such a step would serve to level the playing field across the states, recognizing that nine states have already enacted laws requiring health care employers to take certain steps to protect their employees from episodes of workplace violence, and at least three states (California, New York, and Washington) have state-specific OSHA standards or enforceable guidance, requiring employers to prepare written violence prevention plans. ACOEM believes that the existence of these standards provides strong evidence for the feasibility of a nationwide standard.
Evidence for the effectiveness of these standards is beginning to emerge. For example, in Washington, clinical settings which implemented violence-prevention strategies saw an improvement in other risk factors for violence, and an improvement in worker morale. A recent study at a large Midwest multi-state hospital system and involving nearly 15,000 workers found that on hospital units that had instituted a variety of preventive steps, episodes of violence occurred roughly half as often, an effect that persisted for two years of follow-up. In California’s system of state mental health hospitals, a coordinated approach to controlling both patient-specific and environmental risks for workplace violence reduced certain kinds of violence significantly.
With regard to the specific groups of questions posed by OSHA, ACOEM offers the following comments:
Section II -- no specific comments.
Section III -- Type of violence; definitions ACOEM concurs that the focus of rule-making should be on violent episodes falling into Type II, that is, violence perpetrated by patients or clients against caregivers or against other workers providing service to the client. However, if a workplace has identified other types of workplace violence as a foreseeable risk, a new standard should incorporate standard preventive measures for these types as well.
Question III. 1 -– (definition of workplace violence). ACOEM supports having OSHA adopt a definition of workplace violence that is consistent with existing state standards. For example, the Cal/OSHA standard defines workplace violence as: “(A) The threat or use of physical force against an employee that results in, or has a high likelihood of resulting in, injury, psychological trauma, or stress, regardless of whether the employee sustains an injury; (B) An incident involving the threat or use of a firearm or other dangerous weapon, including the use of common objects as weapons, regardless of whether the employee sustains an injury.”
For purposes of its regulation of public sector employers, New York State OSHA defines workplace violence as: “Workplace violence is any physical assault or act of aggressive behavior occurring where a public employee performs any work-related duty in the course of his or her employment, including, but not limited to:
- An attempt or threat, whether verbal or physical, to inflict physical injury upon an employee;
- Any intentional display of force which would give an employee reason to fear or expect bodily harm;
- Intentional and wrongful physical contact with a person without his or her consent that entails some injury; or
- Stalking an employee with the interest in causing fear of physical harm to the physical safety and health of such employee when such stalking has arisen through and in the course of employment.”
Section IV -– No specific comments
Section V -– Risk Factors and Controls/Interventions
ACOEM concurs that the risks of workplace violence to be assessed and controlled by employers fall into several categories, as listed in the OSHA Guidance Document (3148, 2015). ACOEM believes that employers are much more likely to take a systematic approach to assessing and controlling these risk factors if required to maintain a written Violence Prevention Plan, updated periodically, with a requirement that workers be included in the preparation and periodic review of the plan. Furthermore, key steps implementing the plan will involve the use of well-designed checklists, especially for two types of activities: environmental hazard assessments and investigation of workplace violence episodes that have come to management’s attention. We believe that workers must have input into the content of these checklists, so that important factors are not omitted. The newly promulgated Cal/OSHA standard referenced above contains a list of items that should be included on such checklists, including risk factors related to staffing adequacy. Health care workers and administrations are already experienced in using checklists to drive patient safety improvements and should find the methodology straightforward to incorporate.
With regard to recordkeeping, ACOEM concurs that an important element of a program to measure and control workplace violence is the maintenance of a log of violent episodes. Such a log will contain information that would not necessarily be captured on the OSHA 300 log. (For example, a “near miss” involving a deadly weapon might result in only a first-aid injury, not requiring entry on the 300 log. Yet, such an episode must nonetheless be captured as an important data point.)
ACOEM further encourages OSHA to promulgate a template or format for uniform gathering of data about episodes of workplace violence, which can then be compared across multiple institutions. ACOEM notes that such a template has been developed by the Occupational Health and Safety Network (OHSN), but might benefit from further refinement. In addition, mandatory reporting would improve data capture relative to an opt-in template, and hence increase its value for designing interventions to decrease the risk of workplace violence.
ACOEM is aware that a number of professional societies with expertise in workplace safety and security have already developed detailed guidelines about how employers can secure their workplaces from episodes of violence, whether from clients (Type II violence) or from others. These organizations have already proved to be valuable resources to health care facilities interested in preventing workplace violence, whether through the preparation of written plans, threat assessments, or staff training. OSHA may wish to include these organizations on its list of resources for employers, including:
- International Association for Healthcare Safety and Security
- International Association of Professional Security Consultants
- ASIS International
- The ECRI Institute
- The Joint Commission
ACOEM strongly supports OSHA’s initiating a rulemaking to address the important problem of workplace violence, especially in higher risk health care institutions and in social service settings, and stands ready to participate in future discussions.
Thank you for your consideration of our comments. Please do not hesitate to contact Patrick O’Connor, ACOEM’s Director of Government Affairs at 703/351-6222, should you have any questions.
James A. Tacci, MD, JD, MPH, FACOEM