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Hospital Workplace Violence Prevention to Face Greater Scrutiny

by | Dec 15, 2022 | Essential, National Lab Reporter, Safety-nir

CMS has instructed state surveyors to crack down on hospitals that don’t implement adequate workplace violence protections.

Violence in the workplace has become a national epidemic. Hazards are especially high in healthcare settings where the potential for violent attack by or against staffers, visitors, and patients is a constant threat. In addition to protecting against bloodshed and injury, taking steps to identify, assess, and minimize workplace violence hazards is a compliance imperative under not just Occupational Safety and Health Administration (OSHA) laws, but also Medicare Conditions of Participation (CoP). The latter has assumed a new urgency now that the Centers for Medicare & Medicaid Services (CMS) has instructed state surveyors to crack down on hospitals that don’t implement adequate workplace violence protections.

The New CMS Workplace Violence Memo

Published on Nov. 28, the CMS memo warns that acts of workplace violence are disproportionately common at hospitals and other health facilities, citing a 2020 Bureau of Labor Statistics Fact Sheet finding that 73 percent of all nonfatal workplace injuries due to violence in 2018 were suffered by healthcare workers, a rate that has been steadily climbing for over a decade. “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,” the memo declares.1

In addition to being a mandate under federal and state OSHA laws, the duty of employers to ensure a workplace free from violence is part of CoPs for Medicare certified hospitals, specifically Section 482.13(c)(2), which states that patients have a “right to receive care in a safe setting.”2 CoP Section 482.15(a) also requires hospitals to implement an emergency preparedness plan that must be based on a risk assessment, CMS notes.

Of course, none of this is a secret. In sending the memo, CMS is basically calling on state surveyors to hold hospitals accountable for compliance with workplace violence obligations while carrying out inspections. It’s “incumbent on the leadership at…healthcare facilities to ensure they provide adequate training, sufficient staffing levels, and ongoing assessment of patients and residents for aggressive behavior and indicators to adapt their care interventions and environment appropriately,” the memo instructs.

Compliance Game Plan

The punchline: Like OSHA inspectors, state surveyors will be scrutinizing your workplace violence prevention programs, policies, and procedures. While rules may vary by jurisdiction and regulatory agency, there are eight basic measures labs and other healthcare providers are expected to do to protect their staff and patients against risk of violence in the workplace.

1. Do a Workplace Violence Hazard Assessment

Designate a competent person with the necessary knowledge, skills, and experience to perform a workplace violence hazard assessment for your facility, considering five risk factors:

  • Previous incidents of workplace violence at the site;
  • History of violence in your neighborhood—ask your local police or law enforcement agency for data and advice in assessing the neighborhood;
  • Circumstances outside the workplace that could lead to violence in the workplace, such as domestic abuse or family violence;
  • The physical design of the workplace; and
  • Current measures in place to protect employees’ health and safety—Tip: have employees fill out an anonymous survey relating their own experiences and survey supervisors separately.

2. Implement Measures to Control Identified Violence Risks

Implement measures to eliminate or, if that’s not reasonably possible, minimize the risks identified in your assessment, including engineering controls such as bulletproof glass partitions, cameras and alarms, and work and administrative controls affecting how work involving risk of violence is carried out. Incorporate your controls into a prevention policy or plan (which we’ll refer to as “policy”).

3. Implement Workplace Violence Response Procedures

You need procedures that lab employees can use to summon immediate help and report acts or threats of violence without fear of reprisal. You also need to ensure that employees are aware of and prepared to use these procedures.

4. Implement Procedures for Investigating Violent Incidents

You must have adequate procedures for documenting and investigating reports of workplace violence, as well as resolving problems and taking corrective actions based on investigation results. Reports of violence should be thoroughly and immediately investigated by competent and impartial personnel who provide a written report and recommendation based on their findings.

5. Provide Appropriate Support for Victims

Offer appropriate support to employees and patients who are the victims of workplace violence, including recommending that they consult a doctor or health professional of their choice for referral or treatment for any injuries or harmful symptoms they suffer.

6. Discipline Employees Who Commit or Threaten Violence

You must have and properly implement a disciplinary policy for workplace violence that:

  • Clearly defines workplace violence and how and where it can occur;
  • Clearly states that acts and threats of violence are grounds for discipline up to and including termination—while “zero tolerance” strikes the right tone, the actual policy should give you the flexibility you need in enforcing it;
  • Is consistently enforced; and
  • Is consistent with the disciplinary terms contained in the collective bargaining agreements affecting covered employees who belong to a union.

7. Provide Appropriate Training & Instruction

You must notify employees who are exposed to violence hazards of the risks they face. In some states, notification may include letting employees know about any co-workers with a history of violence that they’re likely to encounter in the course of work. Caveat: To minimize risk of liability under privacy laws, disclose only the minimum personal information about the violent co-worker necessary to put the employee on notice. For example, indicate that a lab worker has a history of violence without disclosing his or her actual diagnosis or describing previous attacks. Provide training and instruction to employees before they’re exposed to violence risks covering:

  • The measures in place to protect them against workplace violence;
  • How to report incidents or threats of violence to organization officials; and
  • How you investigate and respond to incidents, threats, and complaints of violence.

Keep records documenting that such training was provided and that employees actually understood it. Inspectors will want proof that employees demonstrated competence in their training, e.g., by passing a post-training quiz.

8. Monitor the Effectiveness of Your Prevention Measures

Preventing workplace violence requires continuous engagement, monitoring, and correction. Review your policy at least once a year and immediately in response to:

  • Incidents of violence at your workplace;
  • Changes in work conditions, including renovations and other physical changes to the workplace that your current measures don’t address;
  • The workplace safety committee or individual workers complaining or pointing out deficiencies in your policy; and
  • Any other indications that your current measures may not be effective.


  1. https://www.cms.gov/files/document/qso-23-04-hospitals.pdf
  2. https://www.law.cornell.edu/cfr/text/42/482.13

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