Issued: 1/95 Revised: N/A

Violence in the Workplace

The Kaiser Permanente Medical Care Program of Northern California (KP) will take all reasonable actions to provide a safe environment for all persons who are working in the KP workplace or using KP services. Acts and/or threats of violence by employees or physicians on KP premises, including carrying weapons in other than an official capacity, will not be tolerated and will be grounds for appropriate remedial action. Similarly, acts and/or threats of violence by patients or visitors against employees or physicians will not be tolerated and will be grounds for appropriate remedial action.

The purpose of this policy is to establish a consistent and effective process to respond to acts or threats of violence.

All employees, physicians, members, patients, students, volunteers, contractors and visitors.

All employees, physicians, and members of management are obligated to report any incident where they believe they have been the subject of actual or threatened violence, or have observed or otherwise learned of such conduct by any person employed by KP, using KP services or on KP premises.

These incidents should be reported to the Department Manager and Security Services immediately.

Incidents to be reported include acts or threats of violence which manifest themselves in the workplace; acts or threats of violence stemming from workrelated issues which manifest themselves either within or outside the workplace environment; and acts or threats of violence which may be unrelated to the workplace but which manifest themselves within the workplace.

Following assessment of the severity of any act and/or threat of violence, situations which may seriously compromise local or KP interests must be reported in accordance with Standard Procedure 97A, "Reporting Suspected, Threatened or Actual Criminal Activity at a Kaiser Permanente Facility".

Retaliation against anyone who reports acts or threats of violence, or who participates in any procedures or investigations related to such complaints, will not be tolerated.

Regional Offices and Customer Service Areas are responsible for developing a Threat Management Plan (see section VII) and designating a core group of individuals who will be responsible for Plan implementation in response to any reports or actions by employees, patients, or other persons which are or may be in violation of this policy. Such plans must meet the requirements of state and federal law and regulations including, but not limited to, the California Occupational Health and Safety Act and California Health and Safety Code 1257.7 & 1257.8 (Hospital Security Act).

Regional resources are available to assist Customer Service Areas and Regional Office staff as follows:

Regional Security provides specialized personnel protection services and specialized investigations.

Regional Legal assesses potential legal issues and initiates and manages any services which may be required through the courts (e.g. restraining orders, injunctions and criminal prosecutions).

Regional Human Resources assists with questions involving the application of benefits, human resources policies, and/or contractual interpretations.

Regional Employee Assistance coordinates clinical assessment and fitness for duty evaluations of employees deemed to be potentially violent towards themselves and/or others and also coordinates trauma response services.

Regional resources may also include the coordination of outside consultants who may be retained for threat assessment and case management support, as appropriate.

The following are minimum elements required of a Threat Management Plan:

Distribution of this policy, or one which is consistent with this policy. The policy must clearly forbid acts and/or threats of violence either in the workplace or which might affect the workplace. It must include a clear statement of the duty of all persons to report acts and/or threats of violence and that there will be no retaliation for providing notice of acts and/or threats of violence. The policy should be regularly reviewed with employees, physicians, members, patients and contractors.

Designation of a core group of individuals who will be responsible for implementing the Threat Management Plan. The composite of these individuals should represent a multi-disciplinary perspective, including representatives of Administration (both TPMG and KFH/KFHP), Security, Human Resources and Employee Assistance. A member of the medical center staff (e.g., Social Services or Nursing Management) should be specifically identified to whom incidents of patient violence can be reported and assessed for the possibility of future violent behavior by a patient. Those individuals assigned to implement the Threat Management Plan should not include anyone who is personally involved in the specific situation or who is a target of the act or threat of violence.

Staff training and intervention procedures which enable staff to effectively recognize and respond to violent behavior, to include warning signs of potential violence; conflict resolution; managing difficult situations; and workplace violence protocols.

A protocol for an immediate followup plan to actual acts and/or threats of violence which should include the following elements:

Designation of appropriate levels of authority for decision making.

Prompt, thorough, factual and coordinated investigation of all reports.

Consideration of privacy and confidentiality issues. Notification should be strictly limited to those persons who have a need to know, to include those individuals administering the Threat Management Plan, potential identifiable victims of the threat, local police authorities and administrative staff.

Conscientious designation of persons who should receive confidential reports related to the incident.

Early and continuing assessment of the seriousness of the situation. This assessment should include an evaluation of the type of risk, the nature and severity of the potential harm, the likelihood that the potential harm will occur and the imminence of the potential harm.

Coordination with regional staff and resources(see section VI), as appropriate.

Utilization of fitness for duty, other psychological examinations, or collateral interviews with witnesses or victims for fact finding and/or risk assessments.

Confidential counseling and other support services for victims and witnesses separate from any fact finding and/or risk assessment functions.

Timely and reasonable response to the situation following an assessment of all facts identified during the investigation.

Appropriate case response for varied situations (e.g. critical incident stress debriefing or threat response).

Consistent provision of benefits and support services for victims and witnesses in comparable situations.

Security and safety assessment as required by California Health & Safety Code Section 1257.7 & 1257.8 for Hospitals and Emergency Departments, including an assessment of trends of aggressive and violent behavior and required training for staff, periodic reevaluation of physical security applications (e.g., access control procedures, camera installation alarms or distress buttons), and the establishment of a viable security management plan that will ensure a sustained level of security preparedness in vulnerable areas such as Emergency Departments.

Work site analysis to assure there are no hidden hazards or unsafe conditions (e.g. unlighted areas or areas where access should be restricted because of the probability of violence).

Consistency with regional policies on related issues including Human Resource policies #3.08, "Disaster Planning" and #3.09, "Bomb Threat", Standard Procedure 97A, transfer laws regarding psychiatric patients, and Health Plan protocol for termination for cause.

Number: 5.04 SC Supersedes: N/A

Issued: 2/3/97 Revised: N/A

All employees, physicians, members, patients, students, volunteers, contractors, and visitors to Kaiser Permanente property.

To safeguard all staff, members and visitors by addressing threats and aggressive behavior at the earliest stage. To define inappropriate and unacceptable workplace behavior. To establish expectations and guidelines for reporting and managing threats, aggressive behavior, stalking and violence. POLICY STATEMENT

Kaiser Permanente acknowledges the risk of violence in the workplace which can result in tragic consequences for our staff, our members, and visitors to our facilities. We are determined to take all reasonable preventive measures to provide a safe environment for everyone on our premises. Acts or threats of violence by employees, physicians, members, and visitors on Kaiser Permanente premises will not be tolerated. Threats or acts committed off premises against or by an employee, physician or member which arise from a relationship with Kaiser Permanente are likewise unacceptable. Any such threat or act will be considered grounds for remedial action.The carrying, possession, or use of any weapon on Kaiser Permanente property by any person is strictly prohibited. The only exceptions to this prohibition are:

Local, state and federal law enforcement personnel who are required by their agencies to carry weapons.

Other persons who are expressly requested by Kaiser Permanente to be on company property when there is evidence to support a high probability of imminent danger of injury or death. Authorization to carry a weapon must be given by a Kaiser Permanente Facility Security Director and the Regional Director of Security, in consultation with the local area administrator or designee.

believe they have been the subject of actual or threatened violence arising out of their relationship with Kaiser Permanente, or observe or otherwise learn of such conduct by any person employed by Kaiser Permanente, using Kaiser Permanente services, or on Kaiser Permanente premises. Visitors to our premises are encouraged to make reports when similar circumstances apply. Employees shall encourage such reporting and will assist in the process.

Incidents to be reported include stalking, acts or threats of violence which occur in the workplace, or acts or threats of violence stemming from work-related issues which occur either in or outside of the workplace.

No retaliation of any kind will be taken against anyone who, in good faith, reports acts or threats of violence, or who participates in any action or investigation related to such complaints.

All reports will be evaluated promptly, and appropriate action will be taken.

Each Member Service Area (MSA) and Regional Services will establish at least one Threat Management Team. This team will be responsible for developing, implementing, and overseeing a local area Threat Management Plan, and directing a response to any act which may be a violation of this policy. Additional teams will be established if deemed appropriate to ensure compliance with this policy.

The Team will include representatives from Administration, Human Resources, Employee Assistance, Security, Member Services and the Legal Department. The Team may expand its membership as it deems necessary.

The Threat Management Plan will include, but not be limited to:

Periodic review of security systems and procedures.

Development and periodic review of procedures for reporting, assessing, and managing threats and violent incidents.

Education and communication to employees, physicians and members.

Analysis of trends and patterns in order to update preventive measures.

The Plan must meet the requirements of state and federal law and regulations including, but not limited to, the California Occupational Health and Safety Act and California Health and Safety Code 1257.7 and 1257.8 (Hospital Security Act).