List names and job titles for persons responsible for implementing plan and effective procedures.
- A requirement for cultural competency training and equity, diversity, and inclusions training.
- The Preparedness and Incident Response action plans must include procedures to communicate with HCW regarding WPV matters, including:
- How HCW will document and communicate to other HCWs and between shifts and units’ information regarding conditions that may increase the potential for WPV incidents.
- How HCW can report a violent incident, threat, or other WPV concern.
- How HCW can communicate WPV concerns without fear of reprisal.
- How HCW concerns will be investigated, and how HCWs will be informed or the results of the investigation and any corrective actions to be taken.
A hospital must provide training to all HCWs employed or contracted with the hospital on safety during acts of violence. Each HCW must receive safety training during the HCWs orientation and before the HCW completes a shift independently, and annually thereafter.
Training must include:
- Safety guidelines for response to and de-escalation of an act of violence.
- Ways to identify potentially violent or abusive situations, including aggression and violence predicting factors.
- The hospital’s Preparedness and Incident Response action plans, including how the HCW may report concerns about WPV within each hospital’s reporting structure without fear or reprisal, how the hospital will address WPV incidents, and how the HCW can participate in reviewing and revising the plan.
- Sharing resources available to HCWs for coping with incidents of violence, including but not limited to critical incident stress debriefing or employee assistance programs.
As part of its annual review of Preparedness and Incident Response action plans, the hospital must review with the designated committee:
- The effectiveness of its Preparedness and Incident Response action plans, including the sufficiency of security systems, alarms, emergency responses, and security personnel availability.
- Security risks associated with specific units, areas of the facility with uncontrolled access, late night shifts, early morning shifts, and areas surrounding the facility such as employee parking areas and other outdoor areas.
- The most recent gap analysis as provided by the commissioner.
- The number of acts of violence that occurred in the hospital during the previous year, including injuries sustained, if any, and the unit in which the incident occurred.
- Evaluations of staffing, including staffing patterns and patient classification systems that contribute to, or are insufficient to address the risk of violence.
- Any reports of discrimination or abuse that arise from security resources, including from the behavior or security personnel.
As part of the annual update of Preparedness and Incident Response action plans, the hospital must incorporate corrective actions into the action plan to address:
- WPV hazards identified during the annual action plan review
- Reports of WPV
- Reports of WPV hazards
- Reports of discrimination or abuse that arise from the security resources
Following the annual review of the action plan, a hospital must update the action plans to reflect the corrective actions the hospital will implementation to mitigate the hazards and vulnerabilities identified during the annual review.
A hospital shall create and implement a procedure for HCW’s to officially request of hospital supervisors or administration that additional staffing be provided.
The hospital must document all request for additional staffing made because of a HCW’s concern over a risk off an act of violence.
If the request for additional staffing to reduce the risk of violence is denied, the hospital must provide the HCW who made the request a written reason for denial and must maintain documentation of that communication with the documentation of requests for additional staffing.
A hospital must make documentation regarding staffing requests available to the commissioner for inspection at the commissioner’s request. The commissioner may use documentation regarding staffing requests to inform the commissioner’s determination on whether the hospital is providing adequate staffing and security to address acts of violence and may use documentation regarding staffing requests if the commissioner imposes a penalty.
A hospital must make its most recent action plans and most recent action plan reviews available to local law enforcement, all direct care staff and, if any of its workers are represented by a collective bargaining unit, to the exclusive bargaining representatives of those collective bargaining units.
Deadline of report submission to MDH: January 1, 2025.
