Fighting Violence in Health Care Settings
Violence in health care settings occurs with rising frequency, costing facilities, insurers and society dearly, but many incidents can be deterred – and many facilities already have the tools to exert the deterrence.
As bearers of bad and even heartbreaking news, doctors and other caregivers are at high risk for assaults and “active shootings.”
With 154 hospital-related shootings between 2000 and 2011 that left 235 dead or injured, according to the American College of Emergency Physicians, “we’re on notice for the potential for violence,” said Pamela Popp, executive vice president/chief risk officer, Western Litigation.
Health care workers are injured through violent acts at more than four times the national rate, according to the Bureau of Labor Statistics. FBI statistics show a rising trend in active shooter incidents in health care settings, from 6.4 per year between 2000 and 2006, to 16.4 per year between 2007 and 2013.
Those are scary numbers. But there are tools to forestall violent acts in hospitals and some of them don’t cost that much.
“Empathetic communication is key,” said John Walpole, area senior vice president, Arthur J. Gallagher & Co. The techniques that help hospital medical staff de-escalate situations and repair broken conversations can also help front-line employees.
“We can’t wait for something to happen. We have to have a prepared response.” — Pamela Popp, executive vice president/chief risk officer, Western Litigation
“The good news is that organizations can use their own low-cost resources,” he said.
“They don’t always need to bring in expensive trainers and consultants.”
Organizations can benefit from training everybody who comes into face-to-face or phone contact with patients and relatives.
That could include contractors, social workers, facilities staff, superintendents and engineers — who double as security staff in small facilities — food service personnel and triage nurses.
Receptionists are a particular target of people who arrived angry or became frustrated by long waits in a hospital lobby or emergency room and should definitely be included in such training.
Workers welcome training in this regard, Walpole said.
The journal “Prehospital and Disaster Medicine” reports that emergency medical service responders “felt better prepared to respond to an active shooter incident after receiving focused tactical training.”
Taking Corrective Action
Complacency is dangerous, Walpole warned, and risk managers shouldn’t assume their facilities are doing everything that can be done to keep employees safe.
“Run a drill, take corrective action and then test it with another drill. Keep monitoring.”
Hospitals have considerable experience with infant abduction drills, he said, and now those processes must be applied to emergency room violence and active shooter scenarios.
“We can’t wait for something to happen. We have to have a prepared response,” Western Litigation’s Popp said.
That means, she said, that senior management should dedicate security resources. Even if organizations can’t afford onsite security personnel, they should talk to their crime, malpractice and general liability carriers about prevention, both through incident de-escalation and securing the facility.
They may qualify for grants through Homeland Security and FEMA programs.
“Risk managers may assume they have it under control,” but after a safety audit may “find they’re not quite as prepared as they thought.” — Beth Berger, managing director, healthcare practice, Arthur J. Gallagher & Co.
Insurance brokers, carriers and consultants also play a role in workplace and patient safety training, said Beth Berger, a managing director with Arthur J. Gallagher’s Healthcare Practice.
But Berger said the broker community doesn’t always offer these services and clients often don’t ask for them.
“There should probably be more discussion up-front with brokers and carriers,” she said.
“Risk managers may assume they have it under control,” but after a safety audit may “find they’re not quite as prepared as they thought.”
Government agencies and nonprofit organizations, including the Occupational Safety and Health Administration, the Centers for Disease Control, the Joint Commission and the American Hospital Association, also offer free or low-cost resources.
Which Coverage Responds?
While active shooters grab headlines and represent a very real threat, they are hardly the only source of violence in U.S. hospitals and other health care facilities. Which coverage responds depends on the situation: where the incident occurred, who perpetrated it, and who or what was injured or damaged.
In a true crime situation, Popp said, the general liability or captive coverage could respond, assuming one or the other covers crime. If not, facilities can buy violent and malicious acts (crime) coverage, which picks up expenses that wouldn’t fall under a property policy.
“Total losses in an incident are hard to calculate and often underestimated.” — Pamela Popp, executive vice president/chief risk officer, Western Litigation
In patient-on-worker crime, workers’ compensation responds. If other patients are hurt in the event, general liability responds, as is the case with property damage (such as cars caught in the crossfire during a parking lot shooting).
In some cases, losses won’t be covered, and facilities should expect to make payments from the operations budget.
The scenarios are endless, said AJG’s Berger. A stranger with criminal intent mugs a visitor in a parking lot. A grieving relative assaults a nurse. An agitated and disoriented senior in a nursing home strikes a nurse.
Then, there’s worker-on-worker assault, or the angry ex-spouse marching in with a weapon. If an innocent bystander becomes collateral damage in any of these assaults, the insurance questions multiply.
When working through a violence prevention plan when an incident is still theoretical, Popp recommends identifying which coverage will apply in a variety of scenarios.
“After an event, there’s so much chaos and emotions are so high that you’ll be too distracted to figure it out then.”
Total losses in an incident are hard to calculate, Popp said, and often underestimated. The cost of medical care for an injured staff member averages $90,000, and the total cost of an incident could easily reach $500,000 to $1 million when the myriad, often-forgotten peripheral expenses are included.
Popp calculates the total cost of a violent incident by including treatment for:
- Injured staff members (workers’ compensation)
- Non-employees and patients (general liability)
- Patients (professional liability)
Peripheral expenses may include:
- Property damage (general liability)
- Emergency response, such as police
- Business interruption and lost revenue
- Media, such as public relations and crisis management agencies
- Lost time from work for injured and traumatized staff
- Staff counseling
- Potential litigation
Violence in health care settings is “a big problem” from financial and social risk perspectives, Popp said.
Leaders should ask themselves, ‘Is our facility safe? Are we at least keeping up with safety standards of other facilities in the area?’ ” Failure to do so, she said, not only violates the social contract that says that hospitals are safe places, but it also casts uncertainty on insurance coverage.
“We can’t tell ourselves, ‘It won’t happen here.’ ”
When Yelp Reviews Are Better Than Hospital Rating Systems
There is widespread industry agreement that moving towards reimbursing quality versus quantity of care is an important means for controlling medical costs. But how do we define “quality?” And, how do we quantify “quality”?
A recent Health Affairs study illustrates the difficulty of those questions.
The study reviewed four popular hospital rating services (Consumer Reports, Leapfrog, Healthgrades, U.S. News & World Report), and the measures they used were so divergent that their rankings became strikingly different:
- Not one hospital received high marks from all services.
- Only 10 percent of the hospitals rated highly by one service also received top marks from another.
- Twenty-seven hospitals were simultaneously rated among the nation’s best and worst by different services.
We deal with this frequently in our networks. We’ll have one client “absolutely” refuse to work with a provider, while another “absolutely” demands that same provider in their network.
Why such amazing disparity? It’s apparent that both hospital rating services and our clients utilize different factors to measure quality, and weigh those factors differently.
One scoring system may value cost per episode, while another values cost per diem. Another system might reward great valet parking, while another focuses on infection rates. Even slight variances can massively impact ratings. At this point, a Yelp review is likely just as good … or better.
So how do we get to meaningful provider ratings? It’s clearly a pervasive problem. In Rising’s 2014 Workers’ Compensation Benchmarking Study, medical management ranked as the top core competency impacting claim outcomes, yet only 29 percent of respondents rate their medical providers. As demonstrated by the Health Affairs study, it’s really hard to delineate the best from the worst, and trying to make those determinations can cause organizational paralysis.
So, I recommend starting simple. First evaluate what outcomes are most important. Do you value customer experience, clinical, or financial outcomes and to what degree? Do you weigh factors differently by service type (e.g., MRIs weigh convenience highly; surgeries weigh clinical outcomes highly)? If your measurements don’t correlate with your goals, your process won’t produce valuable results.
Even slight variances can massively impact ratings. At this point, a Yelp review is likely just as good … or better.
After determining your most important factors, then your second step is to carve providers from the bottom. This avoids the inertia that can come from trying to rate “top” providers too soon. It’s much easier to eliminate the outlier providers that cause the majority of bad outcomes to instantly improve your program.
Only after these steps would I recommend trying to establish the “best” providers. The “best” often deal with the most difficult cases, with the longest recovery periods or possibly the “worst outcomes.” It’s easy to see how a gifted surgeon might suffer under many quality rating systems. On a positive note, the transition to ICD-10 will allow provider quality comparisons at a deeper level of specificity never possible with ICD-9. In other words, we’ll actually be able to compare apples to apples over time.
With this three-step iterative approach, you can create and refine measurements that bring real, long-term value to your organization…making your system better than Yelp.
Managing Chronic Pain Requires a Holistic Strategy
Chronic, intractable pain within workers’ compensation is a serious problem.
The National Center for Biotechnology Information, part of the National Institutes of Health, reports that when chronic pain occurs in the context of workers’ comp, greater clinical complexity is almost sure to follow.
At the same time, Workers’ Compensation Research Institute (WCRI) studies show that 75 percent of injured workers get opioids, but don’t get opioid management services. The result is an epidemic of debilitating addiction within the workers’ compensation landscape.
As CEO and founder of Integrated Prescription Solutions Inc. (IPS), Greg Todd understands how pain is a serious challenge for workers’ compensation-related medical care. Todd sees a related, and alarming, trend as well – the incidence rate for injured workers seeking permanent or partial disability because of chronic pain continues to rise.
Challenges aside, managing chronic pain so both the payer and the injured worker can get the best possible outcomes is doable, Todd said, but it requires a holistic, start-to-finish process.
Todd explained that there are several critical components to managing chronic pain, involving both prospective and retrospective solutions.
Prospective View: Fast, Early Action
“Having the wrong treatment protocol on day one can contribute significantly to bad outcomes with injured workers,” Todd said. “Referred to as outliers, many of these ’red flag’ cases never return to work.”
Best practice care begins with the use of evidence-based UR recommendations such as ODG. Using a proven pharmacological safety and monitoring opioid management program is a top priority, but needs to be combined with an evidence-based medical treatment and rehabilitative process-focused plan. That means coordinating every aspect of care, including programs such as quality network diagnostics, in-network physical therapy, appropriate durable medical equipment (DME) and in more severe cases work hardening, which uses work (real or simulated) as a treatment modality.
Todd emphasized working closely with the primary treating physician, getting the doctor on board as soon as possible with plans for proven programs such as opioid Safety and Monitoring, EB PT facilities, patient progress monitoring and return-to-work or modified work duty recommendations.
“It comes down to doing the right thing for the right reasons for the right injury at the right time. To manage chronic pain successfully – mitigating disability and maximizing return-to-work – you have to offer a comprehensive approach.”
— Greg Todd, CEO and founder, Integrated Prescription Solutions Inc. (IPS)
Alternative Pain Management Strategies
Unfortunately, pain management today is practically an automatic move to a narcotic approach, versus a non-invasive, non-narcotic option. To manage that scenario, IPS’ pain management is in line with ODG as the most effective, polymodal approach to treatment. That includes N-drug formularies, adherence to therapy regiment guidelines and inclusive of appropriate alternative physical modalities (electrotherapy, hot/cold therapy, massage, exercise and acupuncture) that may help the claimant mitigate the pain while maximizing their ongoing overall recovery plan.
IPS encourages physicians to consider the least narcotic and non-invasive approach to treatment first and then work up the ladder in strength – versus the other way around.
“You can’t expect that you can give someone Percocet or Oxycontin for two months and then tell them to try Tramadol with NSAIDS or a TENS unit to see which one worked better; it makes no sense,” Todd explained.
He added that in many cases, using a “bottom up” treatment strategy alone can help injured workers return to work in accordance with best practice guidelines. They won’t need to be weaned off a long-acting opioid, which many times they’re prohibited to use while on the job anyway.
Chronic Pain: An Elusive Condition
Soft tissue injuries – whether a tear, sprain or strain – end up with some level of chronic pain. Often, it turns out that it’s due to a vascular component to the pain – not the original cause of the pain resulting from the injury. For example, it can be due to collagen (scar tissue) build up and improper blood flow in the area, particularly in post-surgical cases.
“Pain exists even though the surgery was successful,” Todd said.
The challenge here is simply managing the pain while helping the claimant get back to work. Sometimes the systemic effect of oral opioid-based drugs prohibits the person from going to work by its highly addictive nature. In a 2014 report, “A Nation in Pain,” St. Louis-based Express Scripts found that nearly half of those who took opioid medications for more than a month in their first year of treatment then refilled their prescriptions for three years or longer. Many studies confirm that chronic opioid use has led to declining functionality with reduced ability to recover.
This can be challenging if certain pain killers are being used to manage the pain but are prohibitive in performing work duties. This is where topical compound prescriptions – controversial due to high cost and a lack of control – may be used. IPS works with a reputable, highly cost-effective network of compound prescription providers, with costs about 30-50 percent less than the traditional compound prescription
In particular compounded Non-Systemic Transdermal (NST) pain creams are proving to be an effective treatment for chronic pain syndromes. There is much that is poorly understood about this treatment modality with the science and outcomes now emerging.
Retrospective Strategies: Staying on Top of the Claim
IPS’ retrospective approach includes components such as periodic letters of medical necessity sent to the physician, peer-to-peer and pharmacological reviews when necessary, toxicology monitoring and reporting, and even addiction rehab programs specifically tailored toward injured workers.
Todd said that the most effective WC pharmacy benefit manager (PBM) provides much more than just drug benefits, but rather combines pharmacy benefits with a comprehensive ancillary suite of services in a single portal assisting all medical care from onset of injury to RTW. IPS puts the tools at the adjustor fingertips and automates initial recommendations as soon as the claim in entered into its system through dashboard alerts. Claimant scheduling and progress reporting is made available to clients 24/7/365.
“It comes down to doing the right thing for the right reasons for the right injury at the right time,” Todd said, “To manage chronic pain successfully – mitigating disability and maximizing return-to-work – you have to offer a comprehensive approach,” he said.
This article was produced by the R&I Brand Studio, a unit of the advertising department of Risk & Insurance, in collaboration with IPS. The editorial staff of Risk & Insurance had no role in its preparation.