Form 0920-0914 Committee Chair Interview

Appendix C2:

Nursing Home Administrator - Evaluation of Nursing Home Workplace Violence Prevention Program: Combined Form

Form Approved

OMB No. 0920-0914

Exp. Date 2/29/2016

EVALUATION OF NURSING HOME WORKPLACE VIOLENCE PREVENTION PROGRAM: ABSTRACTION FORM

Nursing home : # patients/year: _______

# beds: _______

# employees: __________

COMMITTEE CHAIR INTERVIEWEE INFORMATION

1. What is your job title? _______________________________________________________

2. How long have you been in your current position? _____________

3. How long have you been the committee chair? _____________

A. WORKPLACE VIOLENCE PREVENTION PROGRAM

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

01 Yes (date implemented :___________) 02 No

If YES:

2. Does the workplace violence prevention plan directly address?

a. Establishment of a violence prevention committee	Yes No
b. Violence Prevention Policies	Yes No
c1. Worker-on-worker violence c2. Patient/family violence against workers c3. Domestic violence (where the victim is an employee) that enters the hospital c4. Criminal activity in and around the hospital c5. Violence against patients &/or visitors	Yes No Yes No Yes No Yes No Yes No
d. Recordkeeping process for tracking violent events	Yes No
e. Incident reporting, investigation, and evaluation methods	Yes No
f. Follow-up medical and psychological care	Yes No
g. 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 30minutes 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 (0920-0914).

3. Is a violence risk assessment completed? 01 Yes 02 No

IF YES:

3a. How often are the assessments completed?

 At least annually  Other: _________________

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

4. How often are the violence prevention policies, procedures and responsibilities updated?  Annually  Other: ___________________________

B. TRAINING

1. Do employees receive workplace violence prevention training?

01 Yes 02 No

IF YES:

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

 At hire  Quarterly  Yearly

 Other: __________________________

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 No	Yes No
Physicians	Yes No	Yes No
Unlicensed support staff	Yes No	Yes No
Managers	Yes No	Yes No
Clerical staff	Yes No	Yes No
Security	Yes No	Yes No
Volunteers	Yes No	Yes No
Other: ___________________________________
c. Are contract employees included in the training?	Yes No	Yes No
d. Are per diem employees included in the training?	Yes No	Yes No
e. Are temporary staff included in the training?	Yes No	Yes No

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. 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 No	Yes No
b. Review of the facility’s relevant policies	Yes No	Yes No
c. Verbal methods to diffuse aggressive behavior	Yes No	Yes No
d. Physical maneuvers to diffuse or avoid aggressive behavior	Yes No	Yes No
e. Appropriate responses to workplace violence, including use of restraining techniques	Yes No	Yes No
f. Reporting requirements and procedures	Yes No	Yes No
g. Location and operation of safety devices	Yes No	Yes No
h. Resources for coping with violence	Yes No	Yes No
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 No	Yes No
j. Information on multicultural diversity to increase staff sensitivity to racial & ethnic issues & differences	Yes No	Yes No
k. Other violence-related topics (Specify: ______________________________________)

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

01 Yes 02 No

7. How often is the training content reviewed?

 Annually  Other: __________________________________

C. RECORD KEEPING OF VIOLENT EVENTS AND INCIDENT INVESTIGATION

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

01 Yes 02 No

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

2. Are incident investigations conducted? 01 Yes 02 No

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 No
b. Cell phones	Yes No
c. Personal alarm devices	Yes No
d. Panic alarms	Yes No
e. Audio surveillance systems	Yes No
f. Video surveillance systems:	Yes No
g. Other:

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

01 Yes 02 No

Additional Comments about Security Services:

F. VIOLENCE PREVENTION COMMITTEE

1. Does the facility have a violence prevention committee?

01 Yes 02 No

IF YES:

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

 Nursing Home Administrators  Risk Manager

 Security Director  Nurse Managers

 Staff Nurses  Staff Physicians

 Other (Specify: ____________________________________________)

1b. What percentage of the committee engages in direct patient contact? ____

1c. How often does the committee meet?

 Quarterly  Yearly  Other: ____________________

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

Completion of annual violence risk assessment	Yes No
Development of a written violence prevention plan	Yes No
Recommendations to the facility to reduce identified risks based on findings of the violence risk assessment	Yes No
Review of the design & layout of the facility as it relates to providing work areas safe from violence	Yes No
Development and maintenance of violence prevention training content and methods	Yes No
Development of strategies for encouraging the reporting of all incidents of workplace violence	Yes No
Development of procedures for reporting violent events	Yes No
Review data from post-incident reports in order to identify trends & make recommendations to prevent similar incidents	Yes No

Additional Comments about the Violence Prevention Committee:

G. REGULATIONS (NJ only)

1. Are you familiar with the NJ Violence Prevention in Health Care Facilities Regulations?

01 Yes 02 No

IF YES:

1a. What do you feel are some of the strengths of the Regulations? ________________________________________________________________________________________________________________________________

1b. What do you feel are some of the weaknesses of the Regulations? ________________________________________________________________________________________________________________________________

H. Organizational-Level Safety Climate

Branch management in this agency…	1 completely disagree	2 disagree	3 neither agree nor disagree	4 agree	5 completely agree
1. Reacts quickly to solve the problem when told about safety and security hazards
2. Insists on thorough and regular safety and security reviews
3. Tries to continually improve safety and security for all workers
4. Provides all the equipment needed to keep workers safe in the field
5. Is strict about working safely when patient caseloads are high
6. Quickly corrects any safety or security hazard (even if it’s costly)
7. Provides detailed safety reports to workers (e.g., injuries, violent events without an injury)
8. Considers a person’s safety behavior when moving-promoting people
9. Requires each case manager to help improve safety and security among the workers he/she supervises
10. Invests a lot of time and money in safety and security training for workers
11. Uses any available information to improve existing safety and security rules
12. Listens carefully to workers’ ideas about improving safety and security
13. Considers safety and security when establishing patient volume and worker schedules
14. Provides workers with a lot of information on safety and security issues
15. Regularly holds safety and security awareness events (e.g., presentations, ceremonies)
16. Gives safety and security personnel the power they need to do their job

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