Workplace Violence Prevention Standards

(New Guidance Released June 18, 2021)

Beginning January 1, 2022, revised workplace violence prevention standards will be implemented and apply to all Joint Commission-accredited hospitals and critical access hospitals. Incidence data portrayed that in 2018, social service and health care employees were five times more likely to experience workplace violence than all other employees combined. In addition, these incidences comprised 73% of nonfatal workplace injuries and ailments requiring time off work. Nevertheless, workplace violence is still underreported, implying that the actual workplace violence rates could be much higher. There are many consequences of increased levels of workplace violence, including job dissatisfaction, high turnover and costs, psychological/emotional distress, and absenteeism.

Thus, the Joint Commission has created new accreditation requirements to guide hospitals in producing robust workplace violence prevention systems. These frameworks will provide information on leadership oversight, policies/procedures, creating reporting systems, data collection/analysis, and training.

The Joint Commission’s Workplace Violence Definition: An act or threat occurring at the workplace that can include any of the following: verbal, nonverbal, written, or physical aggression; threatening, intimidating, harassing, or humiliating words or actions; bullying; sabotage; sexual harassment; physical assaults; or other behaviors of concern involving staff, licensed practitioners, patients, or visitors.

The Joint Commission performed a literature and public field review and sought expert guidance from the TAP and SRP during the development of the new guidelines.

Revisions and Additions to the Workplace Violence Prevention Standards

More information regarding the following revisions to the Joint Commission Workplace Violence Prevention Standards and their requirements can be found here.

Environment of Care

  • Standard EC.02.01.01: The hospital manages safety and security risks

Requirements

  • EP 17: The hospital conducts an annual worksite analysis related to its workplace violence prevention program. The hospital takes actions to mitigate or resolve workplace violence safety and security risks based upon findings from the analysis. (See also EC.04.01.01, EP 1)
  • Standard EC.04.01.01: The hospital collects information to monitor conditions in the environment

Requirements

  • EP 1: The hospital establishes a process(es) for continually monitoring, internally reporting, and investigating the following: Injuries to patients or others within the hospital’s facilities, occupational illnesses and staff injuries, incidents of damage to its property or the property of others, safety and security incidents involving patients/ staff/others within its facilities including those related to workplace violence, hazardous materials (waste spills and exposures), fire safety management problems/ deficiencies/failures, medical or laboratory equipment management problems/ failures/use errors, and utility systems management problems/failures/use errors.
  • EP 6: Based on its process(s), the hospital reports and investigates the following: Safety and security incidents involving patients, staff, or others within its facilities, including those related to workplace violence.

Human Resources

  • Standard HR.01.05.03: Staff participate in ongoing education and training

Requirements

  • EP 29: As part of its workplace violence prevention program, the hospital provides training education, and resources (at time of hire, annually, and whenever changes occur regarding the workplace violence prevention program) to leadership, staff, and licensed practitioners. The hospital determines what aspects of training are appropriate for individuals based on their roles and responsibilities. The training, education, and resources address prevention, recognition, response, and reporting of workplace violence as follows: what constitutes workplace violence, education on the roles and responsibilities of leadership/clinical staff/security personnel/ external law enforcement, training in de-escalation/nonphysical intervention skills/physical intervention techniques/response to emergency incidents, and the reporting process for workplace violence incidents

Leadership

  • Standard: LD.03.01.01: Leaders create and maintain a culture of safety and quality throughout the hospital

Requirements

  • EP 9: The hospital has a workplace violence prevention program led by a designated individual and developed by a multidisciplinary team that includes the following: policies and procedures to prevent and respond to workplace violence, a process to report incidents in order to analyze incidents and trends, the process for follow-up and providing support to victims and witnesses affected by workplace violence including trauma and psychological counseling (if necessary), and reporting of workplace violence incidents to the governing body

Resources

Mitigating Violence in the Workplace

Workplace Violence Prevention Training for Nurses

Active Shooting Planning

Veterans’ Health Administration Workplace Violence Prevention

More resources regarding de-escalation, leadership in developing safety, the prevention of bullying and criminal events, and addressing behaviors that undermine a culture of safety can be found here on the Joint Commission website. The Joint Commission provides podcasts, blog posts, presentations, research resources, newsletters, and an emergency management portal for facilities looking for guidance on preparing for workplace violence.