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.’ ”
Those Darn Tenant Losses: Solutions
With all of the fire causes and losses, what are the landlords and their insurers to do? In Part One, I discussed the drivers for tenant fires and now I’ll propose a solution.
Every day, there seems to be more and more news about fires throughout the country. In some cases, they are beyond our control (for example, arson), but all examples I outlined in Part One seem to be preventable causes of fires.
However, it is beyond a landlord’s control to actually prevent these accidental fires from starting in the first place. As much as landlords want to police tenants and think they can control them, they regrettably can’t stop the negligence and mistakes that lead to these accidental and potentially fatal losses. Unfortunately, it is unrealistic to think that we can prevent these fires completely. But what can we do?
Yes, there is but a small amount of premium to pay for a $1 million tenant policy limit and it creates administrative burdens for landlords, but in today’s smart-app world, I know there must be a simple and straightforward solution.
Landlords do have control of management of the associated losses and preparing for the extent of the damage and loss caused by the fires. In my view, there are two choices available for landlords to deal with and proactively manage this issue:
1. Landlords fund the costs of tenant negligence through their insurance program; or
2. Tenants are held responsible for their negligence.
Many people might say the answer is obvious and the tenant should be held responsible, but why then, in many cases, does the tenant carry no insurance or insufficient limits?
Rarely is the tenant held responsible for the fires that he or she caused. The answers I receive range from administrative costs to the competitive rental market that landlords face while managing vacancies.
Yes, there is but a small amount of premium to pay for a $1 million tenant policy limit and it creates administrative burdens for landlords, but in today’s smart-app world, I know there must be a simple and straightforward solution. There are solutions for tenants to fund these types of losses.
So, what’s stopping us?
I believe the solution is that landlords need to join the insurance community, with insurance companies and landlords aligned. Through collaboration, we can roll out a solution to shift the costs of these losses back to those who cause them: tenants.
They should be held financially responsible for their negligence and the resulting damage. By working together, we can provide an effective solution to minimize landlords’ losses caused by these fires.
Not only will it save money, but it may also save lives. By holding tenants financially responsible for their misconduct, it gives them incentive to be more cautious.
If they cause a fire, not only will they lose their possessions, but they would now be required to pay for the building damage as well. If we can’t prevent all of these fires from starting in the first place, then we can focus on preventing the frequency of resulting losses they cause.
We can work together to make the world a better and safer place for both landlords and tenants.
Detention Risks Grow for Traveling Employees
It used to be that most kidnapping events were driven by economic motives. The bad guys kidnapped corporate employees and then demanded a ransom.
These situations are always very dangerous and serious. But the bad guys’ profit motive helps ensure the safety of their hostages in order to collect a ransom.
Recently, an even more dangerous trend has emerged. Governments, insurgents and terrorist organizations are abducting employees not to make money, but to gain notoriety or for political reasons.
Without a ransom demand, an involuntarily confined person is referred to as ‘detained.’ Each detention event requires a specialized approach to try and negotiate the safe return of the hostage, depending on the ideology or motivation of the abductors.
And the risk is not just faced by global corporations but by companies of all sizes.
“The world is changing. We see many more occasions where governments are getting involved in detentions and insurgent/terrorist groups are growing in size and scope. It’s the right time for a discussion about detention risks.”
— Tom Dunlap, Assistant Vice President, Liberty International Underwriters (LIU)
“Practically any company with employees traveling abroad or operations overseas can be a target for a detention risk,” said Tom Dunlap, assistant vice president at Liberty International Underwriters (LIU). “Whether you are setting up a foreign operation, sourcing raw materials or equipment overseas, or trying to establish an overseas sales contract, people are traveling everywhere today for so many reasons.”
Emerging Threats Driven By New Groups Using New Tools
Many of the groups who pose the most dangerous detention threats are well versed in how to use the Internet and social media for PR, recruiting and communication. ISIS, for example, generates worldwide publicity with their gruesome videos that are distributed through multiple electronic channels.
Bad guys leverage their digital skills to identify companies and their employees who conduct business overseas. Corporate websites and personal social media often provide enough information to target employees who are working abroad.
And if executives are too well protected to abduct, these tools can also be used to identify and target family members who may be less well protected.
The explosion of new groups who pose the most dangerous risks are generally classified into three categories:
Insurgents – Detentions by these groups are most often intended to keep a government or humanitarian group from delivering services or aid to certain populations, usually in a specific territory, for political reasons. They also take hostages to make a political statement and, on occasion, will ask for a ransom.
In other cases, insurgent groups detain aid workers in order to provide the aid themselves (to win over locals to their cause). They also attempt prisoner swaps by offering to trade their hostages for prisoners held by the government.
The most dangerous groups include FARC (Colombia), ISIS (Syria and Iraq), Boko Haram (Nigeria), Taliban (Pakistan and Afghanistan) and Al Shabab (Somalia).
Governments – Often use detention as a way to hide illegal or suspect activities. In Iran, an American woman was working with Iranian professors to organize a cultural exchange program for Iranian students. Without notice, she was arrested and accused of subversion to overthrow the government. In a separate incident, a journalist was thrown in jail for not presenting proper credentials when he entered the country.
“Government allegations against detainees vary but in most cases are unfounded or untrue,” said Dunlap. “Often these detentions are attempts to prevent the monitoring of elections or conducting inspections.”
Even local city and town governments present an increased detention risk. In one recent case, a local manager of a foreign company was arrested in order to try and force a favorable settlement in a commercial dispute.
Ideology-driven terrorists – Extremist groups such as Boko Haram and ISIS are grabbing most of today’s headlines with their public displays of ultra-violence and unwillingness to compromise. The threat from these groups is particularly dangerous because their motives are based on pure ideology and, at the same time, they seek media exposure as a recruiting tool.
These groups don’t care who they abduct — journalist, aid worker, student or private employee – they just need hostages.
“The main idea here is to shock people and show how governments and businesses are powerless to protect their citizens and employees,” observed Dunlap.
Mitigating the Risks
Even if no ransom demands are made, an LIU kidnap and ransom policy will deliver benefits to employers and their employees encountering a detention scenario.
For instance, the policy provides a hostage’s family with salary continuation for the duration of their captivity. For a family who’s already dealing with the terror of abduction, ensuring financial stability is an important benefit.
In addition, coverage provides for security for the family if they, too, may be at risk. It also pays for travel and accommodations if the family, employees or consultants need to travel to the detention location. Then there are potential medical and psychological care costs for the employee when they are released as well as litigation defense costs for the company.
LIU coverage also includes expert consultant and response services from red24, a leading global crisis management assistance firm. Even without a ransom negotiation to manage, the services of expert consultants are vital.
“We have witnessed a marked increase in wrongful detentions involving the business traveler. In some regions of the world wrongful detentions are referred to as “business kidnappings.” The victim is often held against their will because of a business dispute. Assisting a client who falls victim to such a scheme requires an experienced crisis management consultant,” said Jack Cloonan, head of special risks for red24.
Without coverage, the fees for experienced consultants can run as high as $3,000 per day.
Given the growing threat, it is more important than ever to be well versed about the country your company is working in. Threats vary by region and country. For example, in some locales safety dictates to always call for a cab instead of hailing one off the street. And in other countries it is never safe to use public transportation.
LIU’s coverage includes thorough pre-travel services, which are free of charge. As part of that effort, LIU makes its crisis consultants available to collaborate with insureds on potential exposures ahead of time.
Every insured employee traveling or working overseas can access vital information from the red24 website. The site contains information on individual countries or regions and what a traveler needs to know in terms of security/safety threats, documents to help avoid detention, and even medical information about risks such as pandemics, etc.
“Anyone who is a risk manager, security director, CFO or an HR leader has to think about the detention issue when they are about to send people abroad or establish operations overseas,” Dunlap said. “The world is changing. We see many more occasions where governments are getting involved in detentions and insurgent/terrorist groups are growing in size and scope. It’s the right time for a discussion about detention risks.”
For more information about the benefits LIU kidnap and ransom policies offer, please visit the website or contact your broker.
Liberty International Underwriters is the marketing name for the broker-distributed specialty lines business operations of Liberty Mutual Insurance. Certain coverage may be provided by a surplus lines insurer. Surplus lines insurers do not generally participate in state guaranty funds and insureds are therefore not protected by such funds. This literature is a summary only and does not include all terms, conditions, or exclusions of the coverage described. Please refer to the actual policy issued for complete details of coverage and exclusions.
This article was produced by the R&I Brand Studio, a unit of the advertising department of Risk & Insurance, in collaboration with Liberty International Underwriters. The editorial staff of Risk & Insurance had no role in its preparation.