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Identifying and managing safety and security risks in various healthcare settings

Risk Control and Claims Advocacy
N/A

By Nicholas A. Smith Jr., CPP , Maryann McGivney and Doris Fischer-Sanchez | May 26, 2021

Organizational security continues to remain a primary consideration for healthcare leaders and stakeholders.

Organizational security remains a primary consideration for healthcare leaders and stakeholders. In the prevailing pre COVID-19 pandemic security risk environment, program areas of primary concern generally included emergency preparedness, asset protection, patient safety and workplace violence prevention. Prior to 2020, many healthcare organizations focused on protecting employees, visitors and other important components associated with their hospitals, clinics and offices, to include information systems, patient data, brand and reputation. Each of these security program points of emphasis are critical and require continuous proactive implementation and management. Yet, traditional security, sometimes referred to as “guns, gates and guards,” is no longer sufficient to counter the developing risks of concern to healthcare professionals.

Many “lessons learned” have been noted over the past year as we encountered and reacted to the new normal of doing business and providing care while a global infectious disease crisis prevailed. Facility and personnel security have gleaned some new insights into the complexities associated with the healthcare continuum. This article focuses on ambulatory, in-patient, home health and senior living safety and security concerns during and as we recover from the pandemic.

A protective umbrella must extend beyond the hospital entrance and emergency department. While security and healthcare professionals have long recognized this need and worked to accomplish effective security risk mitigation, it is clear in 2021 that more emphasis on the entire continuum must be considered in all phases of security operations, planning and service delivery. There are new considerations driven by work-from-home, telemedicine, home health visits and additional pandemic-driven realities. Our Healthcare Security Cycle (HSC) demonstrates the fluid risk and threat climate potentially impacting all streams of the healthcare continuum.

The cycle indicating how the fluid risk and threat climate potentially impacts the healthcare continuum
Healthcare Security Cycle – Ambulatory, In-Patient, Home Health, and Senior Living Care

As you examine the HSC, consider first determining your organization’s protective priorities. The list of “crown jewels” requiring security may contain more categories than at first anticipated. Next, is security awareness a valued trait within your organization? Security events and incidents may occur anywhere and at any time in the continuum of care. While healthcare is often cited as a field in which violence occurs at a higher rate than elsewhere, we believe that these risks are fully manageable. Using our cycle as an evaluation framework you may mitigate known risks while also identifying potential new troublesome scenarios.

Achieving consistent, risk-driven and effective physical security need not always represent costly systems and technologies. Core healthcare security program areas often include investments in access control card readers and video surveillance systems, but in many environments simply tweaking existing protocols or efficiently utilizing what is already in place may add significant security enhancements to your facilities. Satisfactory outdoor dusk-to-dawn lighting, for example, serves to mitigate risks of crime and intruders. Forbidding the propping of exterior main doors at the healthcare facility minimizes risks of unauthorized entry, elopement and theft. Healthcare environments are unique in that facial coverings have long been common and, in our new normal, most everyone must adhere to Center for Disease Control (CDC) personal protective equipment (PPE) guidelines and local laws related to the mandated wearing of masks. With faces obscured in all places of care, ensure that your organization is requiring 100% use and display of credentials and badges to help maintain easy identification of bona fide staff and patients. 

Finally, remember that “situational awareness” allows us to be conscious of the environment around us. By practicing good situational awareness, we may note any developing risks to personal safety and security. Remain in a state of relaxed awareness throughout your day, calm but attentive to your surroundings. Encourage and train your healthcare organizational staff to be on the lookout for suspect behaviors. Out of place persons or situations will be noted, allowing your organization to act to stay safe.

The action steps toward practicing situational awareness
Situational awareness

Below you will find five top security concerns for each continuum care area. We invite you to consider each of these and act within your organization to self-assess your security and readiness policies posture throughout the care continuum:

Ambulatory

  • Security awareness for responding staff
    • Considerations for risk environments due to local crime
    • Being alert for hostile individuals or groups
    • Civil unrest
  • Aligning police response to ambulatory on-scene activities
  • Ambulance drivers’ security and defensive driver training
    • Ambulance may be seen by offenders as containing prescription medicine with street value
  • Be prepared for disruptive behavior
    • Consider best practice alerts which may reveal a patient’s “degree of danger”
    • Ensure that staff are trained and kept current on tactics for conflict de-escalation
  • Social media threats

In-patient

  • Regularly evaluate existing security program elements to include:
    • Access control
    • Visitor policy
    • Guards
    • Panic devices
    • Lockdown procedures
    • Emergency evacuation
    • Shelter-in-place
  • Implement a robust workplace violence prevention and response policy
    • Enforce no-weapons-allowed policy
    • Zero tolerance for violence policy
    • Encourage employee, patient and visitor reporting of violations and investigate and determine resolution
    • Employ sexual offender and other pertinent database checks for patient visitors or overnight family guests
  • Prioritize emergency readiness and response
    • Active assailant
    • Hostile intruder
    • Severe weather
    • Power outages
    • Missing child or person
    • Infant abduction
  • Verbal abuse
  • Chaos and disorder from patients or visitors

Home health

  • Pre-home visit security preparation
    • Local familiarity and knowledge
    • Be attentive to risk climate
    • Local police and other contacts available and alerted prior in rare instances where needed
    • Know the driving route with options
    • Be cognizant of local temporary safe havens: i.e., public buildings, hospitals, police precincts
    • Ensure that others know each clinician’s schedule and require regular check-ins
    • Consider equipping staff with remote duress alarm functionality
  • Assess the personal security atmosphere upon arrival
    • Alcohol or drugs, drug paraphernalia in the home, intoxicated or drug affected appearing individuals in the home
    • Threatening animals
    • Any weapons seen
    • Become aware of exits from home
    • Never enter or remain if uncomfortable for any reason
  • Hostile home environment
    • Prepare to use conflict de-escalation or management of aggressive behavior tactics, if needed
  • Dangerous area where home care is to take place
    • Work in pairs or have police escort when indicated
  • Threat of risk of on-the-job violence
    • Communicate daily with office: number of visits, order of visits, divergence in schedule, emergency contacts

Senior living

  • Security issues of scams targeting the elderly
    • Be attentive to in-person, identify theft, and cyber security targeting
  • Elopement concerns
    • Memory support and other residents may be protected by the use of door alarms and good facility operational security practices
    • Regularly check care center and all exterior doors to ensure that they are secure
  • Challenges associated with creating and implementing an effective active assailant response plan due to mobility issues of many seniors
    • Active shooter response plans should be personalized to your site and floorplans
    • Consider effective safe havens and sheltering in place
  • Resident aggression/violence
    • Do not overlook concerns of “lateral violence” (employee on employee) in high stress workplaces
    • Enforce no weapons policies
    • Note behavioral red flags and act on them
  • Theft from residents and staff
    • Reiterate room and residence security guidance to staff and residents
    • Advise residents to limit the possession of valuables in their rooms
    • Report unknown persons

Workplace violence remains a top tier concern in our society. In addition to top priority security concerns across the continuum of care, we must emphasize the importance of staying focused on deterring, identifying, and responding to indications or threats of bullying, harassment, intimidation or acts of violence at work. The COVID-19 pandemic has not lessened emotional, financial, personal and professional stresses on individuals. It should be noted that the restrictions placed upon society during the pandemic brought additional aggravated concerns and risks for healthcare providers and organizations. Understandably, the illness, isolation, negative economic outcomes and stress many people are experiencing during the COVID-19 pandemic has impacted behavioral and psychological responses and conduct. Sometimes these issues may escalate into employee, patient, visitor or family-member violence at work.   

Situational awareness

Tuned out Unaware of surroundings
Relaxed awareness Paying attention, but enjoying life
Focused awareness Carefully observing a potential danger
High alert Confirmed threat, need to take action
Comatose In shock, unable to function

Personnel security policies and procedures need to be kept current, and employees must be trained in how to recognize and report on suspicious activities, people, situations and vehicles. Be sure to stay abreast of the local, state, national and global risk environment. Are there any criminal or terrorist trends or threats possibly impacting your healthcare system or care locations? 

In rare instances, persons may descend into violent fantasies when potential mental illness is left untreated. Access to weapons is the second worrisome factor. Be sure to consider implementing robust zero-tolerance policies, carry out employee situational awareness training and remain attentive to any developing threats or violent trends. Proactive mitigation strategies may be linked to each risk of violence possibly impacting ambulatory, in-patient, home health and senior living care operations. We recommend defining and implementing a comprehensive workplace violence prevention and response methodology within your healthcare organization, with an emphasis on prevention. Maintaining a safe and secure workplace yields significant benefits for all. Patients and visitors anticipate a safe environment, it is regulated by compliance authorities and some state and federal laws.

Insurance implications

In contemplating safety risks in the healthcare setting, the patient or resident is often the first consideration. The protection of vulnerable patients and residents should be a priority. Most healthcare professional liability (HPL) policies do not explicitly limit or restrict coverage regarding safety risks for the individuals receiving care. However, these policies do often contain provisions regarding “abuse” or “misconduct,” particularly for senior living. Specific sexual misconduct exclusions and limitations are also common in HPL forms, and often these exclusions are broadened to exclude all “abuse.” Even where a policy may not contain an “abuse” or “misconduct” exclusion, nearly all HPL policies include an exclusion for “expected” or “intended” injuries. Ideally an insured’s policy language would allow for coverage to remain in place for the organization and any insured individuals that were not involved in the alleged abuse, misconduct, expected or intended acts. 

Equally as important as the safety of the patient or resident is the safety of employees. Typically, injured employees are covered under workers compensation (WC), with coverage varying based on the WC laws of the specific state involved. For those organizations where work does not mean a controlled or consistent environment, WC costs can be hard to mitigate and claims challenging to decipher. Where does the workday begin and end for a home care provider, and how do you mitigate risks for employees that work remotely or drive distances as part of their employment? Evaluating the top risks for your organization (beginning with the above top security risks by line of service) can start the journey, followed by robust analytical models to assist in evaluating loss trends and quantifying the impacts of change to assess where outcomes and program costs can be mitigated.

Various other coverages can be implicated by safety concerns as well. General liability may respond to safety events related to third parties (patient’s family, visitors, vendors, etc.), while D&O policies may address challenges to the overall policies, procedure and decisions of directors and officers that influence safety outcomes. Similar to the HPL forms, many of these coverages may have abuse, misconduct, expected, or intended exclusions as mentioned above. Additionally, terrorism exclusions could potentially eliminate coverage where the safety event rises to the definitions as stated in the insurance policy(ies) or interpreted by local courts. 

Given the concerns over several of the aforementioned exclusions and limitations, a number of stand-alone insurance products have been developed to address the uncertainty of coverage. Workplace violence, active assailant, sexual misconduct and terrorism policies are all examples of coverages that have evolved to address the security risks in healthcare. Whether or not your organization should purchase additional coverages to address safety concerns requires a careful assessment of your specific risks, appetite, risk mitigation capabilities and a thorough review of insurance contracts.

Workplace violence prevention

Effective security across the continuum demands an organizational commitment to establishing security awareness and a determined security mindset as a core trait and reputation. Healthcare administrative, nursing, general staff, risk and security professionals should be cognizant of individual behaviors which may signal a person’s potential for violence. Identifying these behavioral red flags is key to preventing unwanted incidents. Ultimately, by way of de-escalation training techniques and other communication strategies, every colleague in the organization should be familiar with behavioral indicators which could suggest that an individual might tend toward aggression. The Willis Towers Watson Security Consulting Practice recommends a focus on “workplace violence prevention” and embedding a zero tolerance for violence at work in an organization’s DNA cannot be overemphasized.   

Policy language review

Identify who is an insured
Note whether claims made or occurrence
Scrutinize coverage triggers
Understand applicable exclusions
Review the definitions included in the policy
Assess applicability of other conditions or manuscripted endorsements
Note the claim/incident reporting criteria
Check with underwriters for guidance
Evaluate language/court interpretations in applicable venue

References

Bowers, L. (2018). The 4 top safety concerns in senior care and how to address them. McKnight’s Senior Living, News, perspective and analysis. Retrieved at: https://www.mcknightsseniorliving.com/home/news/the-4-top-safety-concerns-in-senior-care-and-how-to-address-them/#:~:text=The%20top%20four%20security%20and,according%20to%20an%20International%20Association

Healthcare’s epidemic of workplace violence: 5 top safety challenges and 6 best practices to minimize harm. (2020). Becker’s Hospital Review. Retrieved at: https://www.beckershospitalreview.com/hospital-review/healthcare-s-epidemic-of-workplace-violence-5-top-safety-challenges-and-6-best-practices-to-minimize-harm.html

Home Health Care Workers: Tips for Staying Safe While on the Job. (2021). Retrieved at: https://www.stanleysecuritysolutions.com/article/home-health-care-safety-checklist/

Illinois’s 2014 Workplace Violence Prevention Act (820 ILCS275/) Retrieved at: https://www.ilga.gov/legislation/ilcs/ilcs3.asp?ActID=3512&ChapterID=68#:~:text=(820%20ILCS%20275%2F)%20Workplace%20Violence%20Prevention%20Act.&text=Sec.,1.&text=This%20
Act%20is%20intended%20to,venues%20by%20potentially%20violent%20individuals
.

The OSHA Defense Report – Conn Maciel Carey LLP National OSHA Practice Group Blog Retrieved at: https://oshadefensereport.com/about/. Scaglione, Bernard J. (2019). “Security Management for Healthcare — Proactive Event Prevention and Effective Resolution, Routledge Press.


Disclaimer

Willis Towers Watson hopes you found the general information provided in this publication informative and helpful. The information contained herein is not intended to constitute legal or other professional advice and should not be relied upon in lieu of consultation with your own legal advisors. In the event you would like more information regarding your insurance coverage, please do not hesitate to reach out to us. In North America, Willis Towers Watson offers insurance products through licensed subsidiaries of Willis North America Inc., including Willis Towers Watson Northeast Inc. (in the United States) and Willis Canada, Inc.


Authors

Security Consulting Practice Leader
Risk Control and Claim Advocacy practice
Willis Towers Watson

North America Corporate Risk and Broking - Healthcare Industry Practice Leader

Leader, Clinical and Enterprise Risk Management
National Healthcare Industry Practice

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