Policy and Procedure
Subject:
Violence–Free Work
Place
Classification:
Human Resources/Safety
Reviewed/Revised Date:
Effective Date:
)
Supersedes Date:
Page: 1 of 4
I.
PURPOSE:
To provide uniform guidelines for the prevention or intervention related to violent or threatening behavior involving employees, patients, medical staff, visitors, volunteers, contractors, temporary personnel, and students.
II.
DEFINITIONS:
Threats and Acts of Violence :
Behavior consisting of, but not limited to, any expressed intention, directly or indirectly to:

Harm another individual or oneself

Endanger a group of employees or others on the premises

Destroy personal or organizational property
Threats may be verbal, written, contained in a letter/package, electronic mail, telephone/voice, or overheard in conversations.
Threats made as a joke, prank, in jest, or in connection with horseplay are considered real threats.
Non-Imminent Threat:
Behavior consisting of, but not limited to, actions or statements that are not considered an immediate potential for violence against persons or property. This includes:
 threats,
 harassment,
 intimidation,
 history of physical abuse,
 verbal abuse, and/or
 coercion from employees, patients, customers, visitors, or others.
Imminent or Direct Threat:
Behavior consisting of, but not limited to:
 a potential physical assault or use of a weapon
 actions or statements that have the immediate potential for violence against persons or property
(e.g., breaking or throwing objects, gesturing with a fist, etc.)
Weapon:
Any instrument or device that is at least 3” long with the intent to attack or for defense.
III.
POLICY
It is the policy of ABC Health Center to make every effort to maintain a safe work place environment and protect employees, patients, medical staff, visitors, volunteers, contractors,

Page 2 temporary personnel, and students from harm caused by violent acts of others. Any act of verbal, physical, or emotional assault or threat, which may result in physical or psychological harm, is considered a serious offense and is not tolerated.
Employees are responsible for helping to maintain a safe work place. No employee may commit an act of violence or articulate a threat of violence while on hospital premises, in hospital vehicles, or during working hours (including lunch and breaks) or during nonworking hours when such acts may impact an employee's work performance and/or the safety of others.
Employees who threaten or engage in harassment, intimidation, physical abuse, verbal abuse, stalking or coercion are subject to disciplinary action up to and including termination. This policy does not exempt an employee or non-employee from any legal or civil action.
Appropriate legal action may also be taken against non-employees for violation of this policy.
All employees are required to immediately report any threat or potential violence related to the work place, directed against himself/herself, any co-worker, manager, visitor, student, or other individual on hospital premises, or while conducting business on behalf of the hospital.
This requirement includes violent or threatening acts which occur away from the work place or during non-working hours that may impact the employee's safety at work and/or the safety of other employees.
ABC hospital investigates all reports and takes whatever action is deemed appropriate to protect its employees, patients, visitors, students, and property. This includes conducting inspections and searches without prior notice. ABC may find it necessary to investigate current employees if behavior or other relevant circumstances raise legitimate questions concerning potential threat to the safety of others or oneself. Employees are expected to cooperate in any investigation in ABC’s efforts to maintain a safe work place. Employees failing to cooperate in any investigation/inspection/search are considered to be insubordinate and subject to disciplinary action up to and including termination.
Employees are provided with protection against reprisals for reporting, in good faith, acts of violence in the work place. Employees making malicious or bad faith reports are subject to disciplinary action up to and including termination. This policy does not replace or amend legal, ethical, or professional responsibilities regarding duty to warn or confidentiality issues.
Weapons of any type including those carried by individuals with a valid CCW (Carrying a concealed weapon) permit may not be carried on hospital property without proper written authorization form the Administrator or Administrator-on-call. The only exceptions are weapons in the possession of law enforcement officials and non-hospital security here while in performance of their occupation.
 A “ABC Hospital Does Not Allow Weapons” sign is posted at all ABC entrances.

Violators are subject to removal from the premises and prosecution for trespass.

Employees may not have any weapon in their possession while on ABC premises, in
ABC vehicles, or during work hours (including lunches and breaks) or during nonworking hours when such acts may impact an employee’s work performance and/or the safety of others.

Visitors, patients, contractors. Vendors, or any other non-employed personnel may not bring weapons into any ABC facility.

Page 3

Observation of a weapon in the possession by any individual except those listed exceptions above is considered an “Imminent Threat”. Report this situation immediately to The Safety Officer by dialing “6012” or call “911”. Use an “internal
Code” which for ABC facilities is “Dr. Strong”
to alert if the situation is threatening.
Local Law enforcement is to be called in to assist.

By using this internal code “Dr. Strong” this alerts co-workers that a potentially dangerous situation is occurring. Examples of how you could use this are to say to a co-worker: i.
“Would you do me a favor? While I take this patient/customer back to
Mary’s office, would you let
Dr.Strong
know I will be a running behind for our meeting? “ ii.
“Would you do me a favor? While I take this patient/customer back to Mary’s
Office, would you let
Dr. Strong’s office know there is a patient waiting to see him in the lobby?” iii.
“Would you do me a favor? Would you have
Dr.Strong
paged to _____(give the area you are taking the patient/customer to)?” iv.
If able dial 80 and overhead page “
Dr.Strong
to the _______(give the area you are taking the patient/customer to).”
The Safety Officer will train employees upon hire and annually, relevant to workplace violence prevention and intervention as part of mandatory Safety Education.
IV.
PROCEDURE:
Intervention Plan/Response Plan
1.
Non-Imminent Threat
Employee: o immediately reports all specific occurrences and circumstances to their immediate departmentleader or Charge Nurse, whichever is on duty. o completes the ABC occurrence process
ABC will provide ongoing training. Each Department Leader is responsible for educating their staff on potential signs of violent/threatening behavior and the resources available. Internal and External resources available to employees are: Employee Assistance
Program (EAP), Employee Health, Human Resources and Local Crisis Intervention.
Follow up by Department Leader or Charge Nurse: o Responds to scene and interviews employee making the report o Notifies, Human Resources Director and the administrator on-call during the next business day.
2.
Imminent Threat
Employee or designated department/unit person in charge: o calls the local emergency access number, i.e., 911 or the local law enforcement authorities immediately o the supervisor/manager and Human Resources Director (if available), and the administrator on-call o completes the ABC occurrence process

Investigation/Inspection/Searches:
ABC reserves the right, at all times, and without prior notice, to have local law enforcement inspect and search any and all ABC property, work areas, and personal property brought onto
ABC premises when there is reason to believe the safety of ABC employees may be in jeopardy.
Page 4
Local law enforcement and Department Leader: o respond, investigate, report, and notify Human Resources and administrator oncall. o Leadership/supervisory staff and involved employees support and participate in law enforcement recommendations/investigation.
1) The Safety Officer, Human Resources, Department Leader, and Administration investigate all reports.
2) Local Law Enforcement inspects and searches all ABC property.
3) The Safety Officer generates a report, making recommendations to Administration.
Counseling and Follow-up:
1.
Administration decides on actions to be taken based on the Safety Officers recommendations.
2.
Any employee demonstrating threatening behavior may be required to meet with an
Employee Assistance Program counselor. Refusal to do so may result in disciplinary action up to and including termination.
3.
The threatened employee will be offered the services at EAP and will be informed that actions have taken place with the employee who demonstrated the threatening behavior.
Reviewed & Approved By:
________________________________
CEO
__________________________________
Date
__________________________________
Human Resources Director