Tool: As a part of the new OSHA and TJC Workplace Violence standards, Root Cause Analyses and FMEA were completed on actual events and processes related to care of Behavioral Health Patients. The results of these analyses revealed that staff education and competency were needed specific to this population of patients.
Problem: The problem identified through the analyses was lack of staff knowledge about mental health disease processes and how to engage with this population. The goal was to enhance staff education and competency about how to interact with patients with mental health illnesses to prevent workplace violence to staff or others.
Tool Selection: The use of the Root Cause Analysis and FMEA tools were natural selections based on the reactive and proactive natures of these tools as we worked on addressing actual events as well as preventing future events.
Usage: For actual events related to Behavioral Health patients, such as elopements, violence, attempted self-harm, the Root Cause Analysis and 5-Why Tools were used to identify the Root Causes and any incidental findings. As part of the Workplace Violence FMEA, care of the Behavioral Health Patient was a high risk step.
Results: We created an extensive competency focused on staff knowledge of mental health illnesses and created a monthly educational series entitled ‘Stop the Stigma.’ We are actively monitoring our event reporting and associated Root Cause Analyses to assess staff understanding of and perception of care for patients with behavioral health needs. Reasons for delays.