Form 0920-0914 Committee Chair Interview

Workplace Violence Prevention Programs In New Jersey Healthcare Facilities

Appendix C2

Nursing Home Administrators Committee Chair Interview

OMB: 0920-0914

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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

Line 2

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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