Evaluation Form

Workplace Violence Prevention Programs In New Jersey Healthcare Facilities

10 7 2011attachment-C1

Evaluation Form - Administrators

OMB: 0920-0914

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Form Approved

OMB No. 0920-xxxx

Exp. Date xx/xx/20xx



EVALUATION OF HOSPITAL WORKPLACE VIOLENCE PREVENTION PROGRAM: ABSTRACTION FORM

Shape1

Check if hospital has: Emergency Department: # patients/year: _______

Psychiatric Unit(s): # beds: _______

Voluntary Adm: Y/N Involuntary Adm: Y/N

Detox Unit (stand-alone): # beds: _______


A. WORKPLACE VIOLENCE PREVENTION PROGRAM

1. Does the hospital have a formal written workplace violence prevention plan?

01 Yes 02 No 99 Unknown

If YES:

2. Does the workplace violence prevention plan directly address?

a. Establishment of a violence prevention committee

Yes No

b1. Worker-on-worker violence

b2. Patient/family violence against workers

b3. Domestic violence (where the victim is an employee) that enters the hospital

b4. Criminal activity in and around the hospital

b5. Violence against patients &/or visitors

Yes No

Yes No

Yes No


Yes No

Yes No

c. Recordkeeping process for tracking violent events

Yes No

d. Incident reporting, investigation, and evaluation methods

Yes No

e. Follow-up medical and psychological care

Yes No

f. Directions on how to access the facility’s post-incident response system

Yes No









Public reporting burden of this collection of information is estimated to average 60minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-xxxx).






3. Is a violence risk assessment completed? 01 Yes 02 No 03 Not stated

IF YES:

3a. How often are the assessments completed?

At least annually Other: _________________ 03 Not stated



3b. Which of the following job- or task-specific factors are included in the risk assessment?

Working with unstable or volatile persons

Yes No

Prevalence of weapons on site among patients, family, or visitors

Yes No

Presence of gang members

Yes No

Overcrowding and long waits for service that lead to client frustrations

Yes No

Isolated and/or solo work with patients and/or residents during examinations or treatment

Yes No

Lack of staff training

Yes No

Impact of staffing (including security personnel) as a factor that may increase the risk of violent events

Yes No



3c. Which of the following factors are examined when conducting walk through surveys for hazards in the physical environment?

Physical layout

Yes No

Unrestricted access points

Yes No

Crime rate in surrounding area

Yes No

Non-working alarm systems, communication devices, surveillance cameras and/or mirrors

Yes No

Poor lighting and visibility in facility

Yes No

Poor lighting and visibility in parking areas

Yes No



3d. Trends and patterns of violent events are examined through the collection and review of data? 01 Yes 02 No 03 Not stated


4. How often are the violence prevention policies, procedures and responsibilities updated? Annually Other: ___________________________ 03 Not stated


Additional Comments about Workplace Violence Prevention Program:







B. TRAINING

1. Do employees receive workplace violence prevention training?

01 Yes 02 No 03 Not stated

IF YES:

2. How frequently is the workplace violence prevention training offered?

 At hire Quarterly Yearly

 Other: __________________________ 03 Not stated



3. Length and recipients of workplace violence prevention training:



New Hire

Recurring Training

a. How long is the workplace violence prevention training? (in minutes)



b. Which positions are included in the training?


Nurses

Yes Not Stated

Yes Not Stated

Physicians

Yes Not Stated

Yes Not Stated

Unlicensed support staff

Yes Not Stated

Yes Not Stated

Managers

Yes Not Stated

Yes Not Stated

Clerical staff

Yes Not Stated

Yes Not Stated

Security

Yes Not Stated

Yes Not Stated

Volunteers

Yes Not Stated

Yes Not Stated

Other: ___________________________________



c. Are contract employees included in the training?

Yes Not Stated

Yes Not Stated

d. Are per diem employees included in the training?

Yes Not Stated

Yes Not Stated

e. Are temporary staff included in the training?

Yes Not Stated

Yes Not Stated



4. Which formats are used for the training (check all that apply)?

Lecture format (presentations)

Reading prepared material/handouts in print

Interactive discussions

Role-playing

DVD

Computer-based training activities

Other (Specify: _________________________________________________)

5. Who conducts the new hire training?

Contract with a company that provides training to all new hires

(what company: ____________________________________________)

Contract with a company that provides Train-the-Trainer sessions

(what company: _____________________________________________)

 Department in facility (which department: ____________________________)

 Not stated

6. Who conducts the recurring training?

Contract with a company that provides training to all new hires

(what company: _____________________________________________)

Contract with a company that provides Train-the-Trainer sessions

(what company: _____________________________________________)

 Department in facility (which department: ____________________________)

 Not stated

7. Which of the following components are included in the violence prevention training?


New Hire Training

Recurring Training

a. Requirements of workplace violence administrative rules

Yes Not Stated

Yes Not Stated

b. Review of the facility’s relevant policies

Yes Not Stated

Yes Not Stated

c. Verbal methods to diffuse aggressive behavior

Yes Not Stated

Yes Not Stated

d. Physical maneuvers to diffuse or avoid aggressive behavior

Yes Not Stated

Yes Not Stated

e. Appropriate responses to workplace violence, including use of restraining techniques

Yes Not Stated

Yes Not Stated

f. Reporting requirements and procedures

Yes Not Stated

Yes Not Stated

g. Location and operation of safety devices

Yes Not Stated

Yes Not Stated

h. Resources for coping with violence

Yes Not Stated

Yes Not Stated

i. Summary and analysis of facility’s risk factors identified in the worksite analysis & preventive actions taken in response to the risk factors identified

Yes Not Stated

Yes Not Stated

j. Information on multicultural diversity to increase staff sensitivity to racial & ethnic issues & differences

Yes Not Stated

Yes Not Stated

k. Other violence-related topics

(Specify: ______________________________________)





8. Does hospital staff receive specific training and demonstrations on the security equipment (e.g. alarms and cameras) and how to use it?

01 Yes 02 No 03 Not stated

9. How often is the training content reviewed?

 Annually Other: __________________________________ 03 Not stated



Additional Comments about Workplace Violence Prevention Training:

C. RECORD KEEPING OF VIOLENT EVENTS AND INCIDENT INVESTIGATION

1. Does the facility keep records of all reported violent events?

01 Yes 02 No 03 Not stated

IF YES:

1a. Which department tracks the workplace violence reports?_____________________



1b. What type of data are recorded on the incident reports? (check all that apply)

Incident date / time / location (circle all that apply)

Job title of victim

Activity at the time of the violent event

Perpetrator

 Type of violent event

Weapons used

Description of any physical injuries

Number of employees in the vicinity

 Employee actions in response to event

 Facility actions in response to event

Recommendations

Other (Specify: ____________________________________________

_________________________________________________________)

1c. Are reports tracked electronically?

01 Yes 02 No 03 Not stated



2. Are incident investigations conducted? 01 Yes 02 No 03 Not stated

IF YES:

2a. Who fills out the incident investigation reports? ________________________

2b. What is collected in the incident investigation reports? ____________________________________________________________________________________________________________________________________________



Additional Comments about Workplace Violence Reporting and Investigation:









D. POST-INCIDENT RESPONSE

1. What types of services are available for employees who have been injured during a violent event?

 Critical incident debriefing (by whom: ____________________________________)

 Employee health (medical care) Psychological care/counseling

 Employee Assistance Programs Other: ________________________



E. EQUIPMENT

1. What type(s) of equipment does the facility utilize?

a. Alarm Systems

Yes Not Stated

b. Cell phones

Yes Not Stated

c. Personal alarm devices

Yes Not Stated

d. Panic alarms

Yes Not Stated

e. Audio surveillance systems

Yes Not Stated

f. Video surveillance systems:

Yes Not Stated

g. Other:




2. Are appropriate personnel trained to respond to each alarm system in use?

01 Yes 02 No 03 Not stated



3. Are there trained security personnel posted in emergency departments, psychiatric wards, and in other locations, as needed?

01 Yes 02 No 03 Not stated

IF YES: Where are they posted? ________________________________________________



Additional Comments about Security Services:







H. VIOLENCE PREVENTION COMMITTEE

1. Does the facility have a violence prevention committee?

01 Yes 02 No 03 Not stated

IF YES:

1a. Which job titles serve on the committee? (Check all that apply.)

Hospital Administrators Risk Manager

Security Director Nurse Managers

Staff Nurses Staff Physicians

Other (Specify: ____________________________________________)



1b. What percentage of the committee engages in direct patient contact? ____ 03 Not stated



1c. How often does the committee meet?

Quarterly Yearly Other: ____________________

03 Not stated

1d. Is the violence prevention committee responsible for the following?

Completion of annual violence risk assessment

Yes No Not stated

Development of a written violence prevention plan

Yes No Not stated

Recommendations to the facility to reduce identified risks based on findings of the violence risk assessment

Yes No Not stated

Review of the design & layout of the facility as it relates to providing work areas safe from violence

Yes No Not stated

Development and maintenance of violence prevention training content and methods

Yes No Not stated

Development of strategies for encouraging the reporting of all incidents of workplace violence

Yes No Not stated

Development of procedures for reporting violent events

Yes No Not stated

Review data from post-incident reports in order to identify trends & make recommendations to prevent similar incidents

Yes No Not stated




Additional Comments about the Violence Prevention Committee:








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