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Hospitals on notice about adding measures to curb growing problems of workplace violence


CMS publishes memo to reinforce safety standards for physicians, support staff, and patients.

Hospitals on notice about adding measures to curb growing problems of workplace violence

Health care leaders are on notice that physicians, support staff, and patients deserve and expect care settings free from violence.

The U.S. Centers for Medicare & Medicaid Services’ (CMS) Center for Clinical Standards and Quality published its latest memo on workplace violence in hospitals, a problem that has grown since 2011.

“Exposure to workplace violence hazards come at a high cost; however, with appropriate controls in place, it can be addressed,” the notice said. “CMS will continue to enforce the regulatory expectations that patient and staff have an environment that prioritizes their safety to ensure effective delivery of healthcare.”

Because of the risk, health care leadership must ensure adequate training, sufficient staffing levels, ongoing assessment of patients and residents for aggressive behaviors, and appropriate care interventions and environment. CMS acknowledged Medicare-certified hospitals already have a regulatory obligation to care for patients in safe settings under current Medicare Hospital Conditions of Participation.

“The intention of this requirement is to specify that each patient receives care in an environment that a reasonable person would consider safe,” with standards ranging from infection control to security that affect emotional and physical health and safety, the memo said.

A growing problem

The Nov. 28 memo sent to state survey agency directors included statistics and examples of workplace violence involving clinicians who face risk factors such as working with people who have a history of aggressive behavior, behavioral issues, or are under the influence of drugs.

An April 2020 facts sheet by the U.S. Bureau of Labor Statistics reported health care workers accounted for 73% of all nonfatal workplace injuries and illnesses due to violence in 2018. That number has grown steadily since tracking began in 2011.


In the latest memo, CMS said hospitals must:

  • Identify patients at risk for intentional harm to themselves or others.
  • Identify environmental safety risks, such as ligatures, sharps, access to medications, breakable windows, light fixtures, plastic bags, oxygen tubing, and more.
  • Take steps to minimize risks, while noting not all strategies are appropriate for all units. For example, strategies for a post-partum unit most likely would not be the same as those in an emergency department.
  • Implement training for new staff, with ongoing training recommended at least every two years.
  • Maintain an emergency preparedness plan that accounts for facility risks, community risks, and all hazards.

Lives at risk

Workplace violence in hospitals can lead to dire consequences. CMS used examples from facilities that were cited for failing to meet safety obligations:

A nurse in a unit without adequate staffing was sexually assaulted by a behavioral health patient who was stopped by other patients.

A patient died when staff and law enforcement officers performed a takedown that resulted in a custodian holding down the patient on the floor with his knee on the patient’s back.

A patient who was acting out, was shot in a hospital room by police officers when hospital staff failed to assess the patient and de-escalate the situation.

“These cases highlight systemic failures in facilities that place both patients and staff at risk,” the CMS memo said.

Sounding the call

The CMS memo is the latest to shine light on the problem and potential solutions to improve safety and reduce violence. The Joint Commission this year began including workplace safety measures among its criteria for evaluating and credentialing hospitals.

The National Academy of Medicine and the Association of American Medical Colleges, the American Hospital Association, the American Academy of Family Physicians, the American College of Physicians, the Medical Group Management Association, and the American Nurses Association all have condemned aggression toward medical staff. At least two bills have been introduced in Congress to bolster rules against on-the-job violence and protections for physicians, nurses and support staff.

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Jennifer N. Lee, MD, FAAFP
© National Institute for Occupational Safety and Health
© National Institute for Occupational Safety and Health
© National Institute for Occupational Safety and Health
© National Institute for Occupational Safety and Health
© National Institute for Occupational Safety and Health
© National Institute for Occupational Safety and Health