When The Joint Commission first updated their Standards from the Sentinel Event Alert on Workplace Violence in 2018, our organization created an interdisciplinary team to address this topic using the FMEA tool. Our team of staff and leaders from inpatient and outpatient sites addressed the full scope of workplace violence from the time an employee arrived at work through their leaving at the end of the shift. This tool provided excellent insight and lead to significant actions which served us well for the acquisition of two additional hospitals, enhancement of OSHA and TJC standards and an active shooter event.
Tool: FMEA
Problem: We utilized this tool to assist with self-assessment of the new Joint Commission standards in follow-up to the Sentinel Event Alert. This outcome kick-started initiatives toward workplace violence and support ongoing efforts over the past 6 years to improve our level of safety within our organizations and with our staff.
Tool Selection: We believed that the FMEA framework would allow us to address the entire continuum of the safety of our employees (and patients) and provide a solid foundation for the ongoing work that was needing to be addressed as regulatory requirements changed as well as the changing world environment.
Usage: We developed an interdisciplinary team which was a cross-section of the organization, covering inpatient, outpatient, and off-site locations. The team identified 24 different process steps for employees from the time they arrive at work till the time that they left. From this assessment, 11 high-risk process steps were identified.
Results: We developed an action plan to address the 11 high-risk steps, which included an interdisciplinary team to address the topic of Workplace Violence. We have included updates about Workplace Violence in our monthly system-wide Quality and Patient Safety Forum meeting as well as completing an annual survey of staff.
