…when up pops somebody, eventually…
Interesting story in the news last week about someone infiltrating the perioperative area at a hospital in the Boston area (the news story identifies the hospital, so no need to do that here, IMHO). Every time I see one of these types of stories, it makes me glad that I do not still have operational responsibilities for a hospital security department. (In many ways, I have made something of a career of embracing thankless jobs in the healthcare realm; well, maybe not completely thankless, but it can be tough for folks at the bottom of the healthcare food chain. But enough about that.) Apparently, this individual was able to gain access to the perioperative areas, including the restricted portions, without having an identification badge. Now I will say that, based on my observations, the healthcare industry is much better about wearing ID badges, but I will also say that the OR is a tough spot to practice enforcement of your ID policy, especially during the busy times. And then there is the subject of tailgating, which is a time-honored tradition, particularly when you move to an electronic/badge access solution for controlling who gets where in your organization. And, short of installing turnstiles at all your entry points (now wouldn’t that create some noise?), tailgating is going to continue to be a vulnerability relative to security. Much as learning that the NSA was listening in on lots of conversations, I didn’t find this particular news story, or indeed the event, particularly surprising. In all likelihood it happens more than we know—from salespeople to distressed families to the media, the list of potential candidates for such an incursion is rather lengthy. (I’m sure you can add to that list and please feel free to do so!) The source article for the above story indicates that the individual was identified as an interloper when “physicians caught on” (I could be glib and throw out a “maybe she didn’t know the secret handshake,” but that would be catty), so I guess it’s good to make sure that you have good participation from your medical staff in the matter of ID badge compliance.
All that said, and in full recognition that logic doesn’t always prevail, I have a sneaking suspicion that this might just join active shooter response on the regulatory survey security hot topic list (remember when nuclear medicine deliveries were the flavor of the month?). I think anyone having survey over the next little while would be well-served in considering how to respond to queries regarding access control in your ORs and other areas.
It is a most delicate balance: protecting folks and yet providing access to all the patients we serve. Maybe there will be some grant money floating around that could be used for this purpose—nah!
Patients with high-risk behaviors pose a danger to healthcare staff and other patients and are difficult for healthcare employees to manage. In this live webcast, expert speakers Tony W. York, MS, MBA, CHPA, CPP, and Jeff Puttkammer, M.Ed., will discuss the patient factors that often lead to violent events in the workplace, provide a clear understanding of environmental influences and triggers that contribute to violence, and supply tools and resources to help you reduce the risk of a violent event in your facility. The program is scheduled for Wednesday, January 20 from 1 to 2:30 p.m. ET.
Employees have the power to influence their own safety, but they often lack the proper training. Give your staff the knowledge they need to deal with high-risk patients and keep themselves and their facility safe!
At the conclusion of this program, participants will be able to:
- Define high-risk patient behavior (more than just mental health patients)
- Explain how a balanced approach to patient-focused care and personal safety impacts patient satisfaction and work-related injuries
- Identify how workspace design and medical equipment placement can promote or reduce the safety of staff, patients, and visitors
- Define policies, procedures, and practices aimed at reducing safety risks associated with at-risk patients
- Understand the critical role staff education and training plays in helping provide the culture, tools, and competencies required to successfully reduce and manage patient-generated violence
While the events of recent weeks seem to focus our attentions on the darker side of humanity, before jumping into this week’s “serious” topic, I did want to take a moment to wish you all a most joyous Thanksgiving. Your continued presence in this community is one of the things for which I am thankful, so I will, in turn, thank each one of you for that presence—without you, there wouldn’t be much purpose to this little rant-o-rama! And a special thanks to Jay Kumar from HCPro, who manages to keep things going!
And so, onto the business at hand. In the aftermath of the Paris terror attacks, the folks at the Department of Homeland Security are encouraging hospitals and other healthcare organizations to review our security plans and to work towards exercising them on a regular basis (you can read the full notice here). The notice contains a whole bunch of useful information, including indicators to assist in identifying suspicious behaviors and to build a truly robust process for reporting suspicious activity. It’s always tough to say how much of an event could have been prevented if folks were more skilled in identifying threats before they are acted upon, but I guess we always have to use such events as a means of improving our own situations. At any rate, I think it would behoove everyone in the audience to take a look at the materials referenced in the notice. A lot of times, I think we find ourselves “casting about” for direction when it comes to the practical application of how we become better prepared, particularly in the healthcare world of competing priorities. I also know that it is sometimes challenging to get folks to seriously participate in exercises—I don’t know that we’ll ever completely get away from having to deal with what I will characterize as moderate indifference. The events in Paris (and Mali) only point out that this is a risk shared by everyone on the planet, whether we would want it or not. And the more we educate folks to recognize threatening situations, the better able they will be to keep themselves safe. I wish there were a simple solution to all this, but in the meantime, the strategy of increased vigilance will have to do.
Every once in a while I like to dip into the ol’ mail bag when I get a question that I either haven’t answered before or conditions/practices have changed enough to update an initial response. In this particular instance, we’re covering some territory that I’m pretty sure we’ve not aired previously (as near as I can tell…).
Q: I would like to get your take on patient elopement (or simply leaving without signing, or refusing to sign AMA forms), and the longstanding practice of having security staff, maintenance staff, etc., pursue these patients. These types of things make corporate legal departments cringe, and it leaves Plant Operations directors caught in the middle of “should we respond or not” debates.
A: Thanks for your question. I really think that your description of the reaction of legal departments to the “pursuit” of eloped/eloping patients is pretty much on the money and that’s why (in my mind), they are the ones that need to be the determining factor when establishing a response protocol for elopement. I have certainly worked with organizations for whom a “simple pursuit” protocol has ended very badly with patients injured, and in a couple of instances, worse (I’ll refrain from the details) during response to an elopement. Someone who is eloping tends to want to elude (or otherwise outrun) their pursuers and sometimes they’re not paying attention to where they are going (I liken it to chasing a toddler—the “state of mind” of some of your elopers is not so very far from a toddler—they spend a lot of time looking over their shoulder and not looking where they are going). At the hospital at which I used to work, the legal folks said if the patient eloping leaves the property, then you let them go and call the local authorities (recognizing that their response is going to be dependent on what’s going on in the community) and work (which you can certainly interpret to mean “hope) towards a good outcome. Unless someone is really mentally incapacitated, you can usually figure out where they are going, so that becomes information that can be shared with law enforcement.
All that said, it is of critical importance to have a specific response plan (you can leave a little leeway for specific cases, but you really need to have a consistent overall approach) that has been developed in collaboration with clinical (including physicians), legal, and support leadership. Everyone has to be on the same page if we are not going to be putting anyone (and that includes the folks responding) at risk.
I know this is something that faces healthcare organizations all across the country including, I suspect, some of the folks out there in the audience. So I put the question to you: How are you managing response for eloped patients? Is it a “let them go and call the cops” response protocol or more of a “bring ’em back” response? I suspect that we could have some interesting dialogue on this one, so please weigh in as you can.
In a February 18 Joint Commission leadership blog post, Mark Crafton, TJC’s executive director of communications and external relations, focuses on the benefits of investigating different approaches for mitigating violence in hospitals. At least that’s where the conversation starts, but it ends up in kind of an interesting (and to my eyes, unexpected) direction: the question of whether hospital security officers are a more effective deterrent/mitigation strategy when they are armed. (N.B.: In Crafton’s post, he refers to security “guards”; call me whatever you like, but I think the term “guard” just doesn’t ring well with me. I’m okay with the terms “security staff” or “security officers,” but “guards” just gives me the vapors—metaphorically speaking, of course.)
In the course of the posting, Crafton points to an article in the Chattanooga Time Free Press that will likely generate some debate among healthcare security professionals, and I tend to agree with that thought. Apparently the article was the result of a healthcare system’s decision to disarm their security staff and adopt the “soft” uniform look (e.g., blazers, etc.) to more effectively emphasize the security officer’s role as a more customer-oriented (my description) countenance. Now we’ve touched on the subject of arming security officers in the past (it’s been a really long time) and it’s probably way past the time for looking at this topic, particularly as the good folks at CMS have some rather strong thoughts on the subject:
CMS does not consider the use of weapons in the application of restraint or seclusion as a safe, appropriate health care intervention. For the purposes of this regulation, the term “weapon” includes, but is not limited to, pepper spray, mace, nightsticks, tazers, cattle prods, stun guns, and pistols. Security staff may carry weapons as allowed by hospital policy, and State and Federal law. However, the use of weapons by security staff is considered a law enforcement action, not a health care intervention. CMS does not support the use of weapons by any hospital staff as a means of subduing a patient in order to place that patient in restraint or seclusion. If a weapon is used by security or law enforcement personnel on a person in a hospital (patient, staff, or visitor) to protect people or hospital property from harm, we would expect the situation to be handled as a criminal activity and the perpetrator be placed in the custody of local law enforcement.
The use of handcuffs, manacles, shackles, other chain-type restraint devices, or other restrictive devices applied by non-hospital employed or contracted law enforcement officials for custody, detention, and public safety reasons are not governed by this rule. The use of such devices are considered law enforcement restraint devices and would not be considered safe, appropriate health care restraint interventions for use by hospital staff to restrain patients. The law enforcement officers who maintain custody and direct supervision of their prisoner (the hospital’s patient) are responsible for the use, application, and monitoring of these restrictive devices in accordance with Federal and State law. However, the hospital is still responsible for an appropriate patient assessment and the provision of safe, appropriate care to its patient (the law enforcement officer’s prisoner).
As you can well imagine, equipping security staff with weapons of almost any stripe can result in the classic slippery slope. My personal practice was to have a clear delineation between security staff and law enforcement responders. Security staff were provided ongoing crisis management education and worked closely with clinical staff to proactively manage at-risk situations. Law enforcement response was summoned when appropriate and the use of weapons was solely at the discretion of those responders. I know those lines can get pretty blurry in the heat of the moment, but specific roles are, I think, the best starting point for an effective security program.
At any rate, Crafton goes on to discuss the following: the cases for armed/not armed security staff; armed staff as authority figures vs. armed staff as a potential for raised anxiety of patients who are already distressed/stressed; and how do you make patients and staff safe, etc. There are, of course, good arguments on both sides, but ultimately (and this is one of the common threads when it comes to TJC standards and expectations), it is the responsibility of each organization to determine how best to manage, in this case, security risks. It doesn’t seem likely that peace, love, and understanding are going to be breaking out any time soon; the role of the security officer has never been more important.
As you are all no doubt familiar, sometimes those educational topics surrounding safety can come across as a bit dry and that dryness all too frequently ends up being the focal point of safety presentations. Now, one of the fun little quirky things that you run into when flying is that every time you get on a plane, you have to go through orientation (if only we as healthcare safety professionals could “capture” an audience as frequently as the airlines do) and sometime those orientations are very much less than compelling. And so, I thought that you might find the following offerings from NPR and The Telegraph of some interest, entertainment, and perhaps some inspiration. As I like to say during my consulting visits, this stuff doesn’t have to be torture. At any rate, I hope you enjoy these, and maybe you’ve got some homegrown footage you’d want to share (or perhaps already have shared); there’s no reason we can’t all partake of such splendor.
I don’t hear too many stories like this anymore, but I can tell you, as a former manager of security services at a hospital, this is one that really gives me pause.
In September, at a hospital out in San Francisco, a patient disappeared from her room, after which a search ensued with no result. The awful thing is that the patient was found in a locked stairwell about two weeks later by an engineering staff member doing rounds. You can find the San Francisco Examiner story that caught my eye (as well as several related stories).
Now I’m sure the investigation will yield some indication of what happened, but I’m also thinking that the whole story may never be revealed. Was that stairwell inspected prior to the point when the engineering staff person made their rounds? How was the search conducted? Was there a conscious decision to limit the search to unsecured areas? At what point do you suspend the search?
I’m certainly not going to Monday-morning quarterback such an awful circumstance, but the question I ask myself is this: can you stop looking when you’ve not found the person you’re looking for? Again, it’s my understanding that the stairwell in question was secured, but how many times have you encountered a security system that was absolutely impregnable—my experience has been that the human element is all too frequently the means of defeating the certain security measure. So has this particular tragedy caused anyone to look at, or even rethink, their search protocols? Are there areas you might not consider as being accessible that might warrant at least inclusion in a comprehensive search grid? I’d be interested in what you all think about this one.