And now, I would like to introduce our speaker to get us started. Ms. Laura Dixon most recently served as the Director of Risk Management and Patient Safety for the Colorado region of Kaiser Permanente. Prior to joining Kaiser, she served as the Director of Facility Patient Safety and Risk Management and Operations for COPIC from 2014 to 2020. In her role, Ms. Dixon provided patient safety and risk management consultation and training to facilities, practitioners, and staff in multiple states. Ms. Dixon has more than 20 years of clinical experience in acute care facilities, including critical care, coronary care, perioperative services, and pain management. Prior to joining COPIC, she served as the Director of Western Region Patient Safety and Risk Management for the Doctors' Company in Napa, California. In this capacity, she provided patient safety and risk management consultation to the physicians and staff for the Western United States. As a registered nurse and attorney, Laura holds a Bachelor of Science from Regis University, a Doctor of Jurisprudence from Drake University College of Law, and a registered nurse diploma from St. Luke's School of Professional Nursing. She is licensed to practice law in Colorado and in California. Thank you for being here with us this morning, Laura, and I invite you to go ahead and just get us started. Okay, and thank you very much, Lindsay, and welcome, everyone. We're talking about a topic that, unfortunately, has remained in the news on multiple and multiple occasions, and we'll probably still continue to hear about it. The good news is, if there is good news, is that we are talking about it now, and now we are trying to take steps. Some of you have probably taken steps to help mitigate, if not stop, these events from happening within your facility. Now, of course, I always have to include my disclaimer. The information I'm presenting today is strictly that, informational only. It is not meant to serve as legal advice nor establish an attorney-client relationship, so please consult with your own in-house counsel or professional legal representative for advice, especially as it relates to your facility, your situation, or any particular state law that you have going on. Now, what I want to do is I've got some videos in here, and this one I have permission from the University of Vermont Medical Center, and they put together this video, and it talks about violence against health care providers, and it only runs a couple minutes. I don't think we hear the audio on that, Laura. It may be that whenever you shared your slides, you may not have selected the share with sound option. Oh, my. Okay, and I apologize for that. That's all right. If you want to, probably the best thing would be to stop the share, and then re-share your slides, and then you can select that option to share with sound. Okay. I'm not too sure how to do that, I apologize, Lindsay. That's okay. So, let me see if I can, let's see. Can you hear? If you want to, Laura, you can just stop sharing. You want me to stop that for you? Stop sharing? Okay. Yep. Sorry, I'm definitely having some issues with this. Can you still hear me, Lindsay, or not? I can. I can. Okay. Yeah, I apologize on that. So what I may have to do is just go ahead and perhaps revisit this, and I'll forward you the video. Everything will be available. I do apologize for that. You're good. And everybody has access to the slides, and so if the video is included in there, then they can go back and watch that video in the slides as well. Yes. And again, I do apologize for that. I thought I had it all worked out. Okay. So let's go ahead and move on. And the topics we're covering today, first off, I do want to talk about the conditions of participation, as CMS talks about it. Now, they have started to come around and bring us some more information on violence within the workplace. And we're going to talk also about Joint Commission, because they revised some of their standards on workplace violence, and they came up with three areas that hospitals, especially those with deemed status, need to address. We're going to talk about guidelines from OSHA, the Department of Labor, and then do you want to add in your emergency preparedness standards? Well, those of us who work in healthcare, we never want to see these types of headlines. We've seen that rising incidence within the workplace, and now staff is really starting to speak out. Now, how are you going to keep me safe? How is this going to happen? And those of you who work bedside, you've probably heard it from some of your colleagues that patients are getting nasty sometimes. And it's sometimes because they're just ill, they're scared, and they're getting more abusive. And again, just simple questions can set them off into the violence. So these are some of the items that we had published within our local newspaper here at the Denver Post. And it talks about how it is escalating that now healthcare workers are also seeing that violence. We have a nurse assaulted every 30 minutes within our state. And it's reaching to the point where we're at crisis level. Here's just some examples. And this happened to be from our Denver paper. Patient picked up a heart monitor and threw it at a provider. A patient slapped a healthcare provider just trying to simply adjust an IV. There were racial slurs at healthcare workers during their rounds. And they also published a story about a nurse in North Dakota thrown against a wall and bitten by a patient. These things are starting to reach crisis level, by all means. In Tulsa, Oklahoma, this is where it was really taken to the extreme, where we have a patient who opened fire within the hospital. And as far back as 2017. Now, this is not a new event. We know these things have been occurring for quite some time. Happened at Bakersfield Hospital in December of 17. That door happened to be left unlocked. And that's how the individual gained access. So what is the issue? Healthcare, social work services, they are five times more likely to see violence than any other worker. Made up almost three quarters of our non-fatal injuries. Half of the nurses report increased workplace violence, 119%. That's a huge jump. And we do know it is underreported. I don't know if some of you happen to read, there was an article in the American Nurses Association, where it happened to be a cartoon. And there was a patient in the bed and then the spouse was next to him and the nurse. And the spouse says, you know, I'm so sorry that this happened. My spouse was, he's, they're normally not like this. And the nurse responded, oh, that's okay. It's part of the job. Well, the backlash from that is like, no, it's not part of our job to be hit, to be bitten, to be thrown against a wall, to be assaulted like that. And so the American Nurses Association did reach out to them and say, we need to revisit this because that's not okay. Bureau of Labor Statistics, they have shown back in 2022, that 2.8 million workplace injuries and illnesses were reported. And that healthcare, again, social services, almost 500,000 non-facial injury. These are all due to workplace violence, not other on-the-job injuries. In healthcare, violence from patient, they, we do know that is an occupational hazard. And the early 1990s, so we're going back, what, 10, 20, 30 years, it is recognized as a risk in our healthcare setting. And despite it, well, it's gone up. And of course, those of you who have gone through it, definitely increased during COVID. So what's the cost to this? So if you're wondering, you know, how can I get this across to my governing body? Well, there's a financial impact of that. Per year, 109,000 for one nurse to be injured, up to almost 330 for a single system. Now that's not including psychological trauma, lost work, dissatisfaction, which means higher turnover. Our patient care costs, well, first off, there's the direct because of the actual act. And then again, we have gaps in the nursing shortage. We already have our agencies. We have those who are just saying, I'm not going to do this anymore. It's not worth the injury. And I have a family to think about. If I'm the breadwinner, I need to take care of myself too. Exposure, that can impair effective care. And then it leads to several things. I already mentioned the psychological distress. We're not happy in our job. We just don't want to do it anymore. Absenteeism because of injury or PTSD. It's real. It does happen. High turnover, which of course, the average turnover in five years has gone up almost a hundred percent. Higher costs that have led to all of that. And there is where you will find this information. It's in that article. So we know this is real. So the American Hospital Association also then finally reached out to Congress and they came up to enact safety from violence in healthcare employees. They did. It passed the house. It's still in the Senate. It was still in there as of yesterday when I went in to look. But some of our states are starting to step up. My state has stepped up and said, we're done with this. This isn't going to happen anymore. Now this bill that they put into place requires facilities to put into place and regularly review their workplace violence prevention plan. The plan must be enforced and it must be updated. And this means they are required to submit incident reports related to workplace violence to this state twice a year. And they must offer post-incident services to our affected workers. And so this also happens to be just the fact sheet from the American Hospital Association. Now, Lindsay mentioned we have questions. And what I've done is I've taken this one scenario that's happened at one of my former hospitals. And Lindsay, do you want to go ahead and read the question? Absolutely. I'm happy to. So this question says hospital A's pharmacy is in the basement with locked access and security cameras. Only one pharmacist and one technician are on duty during the night shift. Floor nurses must go to the pharmacy if additional routine medications are needed, including controlled substances. And the question here is what should hospital A include in a risk assessment? And then let's go ahead and get that up here for you to have your options. First is nothing. It is a safe area. Adding staff so no one goes to the pharmacy alone. Ask security to escort nurses or possibly watch the situation. Nothing has happened in the past. And if you did miss our opening, we are going to have a few of these questions throughout the presentation. And during the time of the polling questions, we will pause to address any questions that you have for Laura throughout. And so there at the bottom of your Zoom window, you should see that option that says Q&A. You can click on that and just type in your questions as you think of them. Or if for some reason you don't see that Q&A option, you can, of course, utilize the chat as well. I know there were several questions asking for a link to the slides. I did provide that there for you all in the chat. And then, Laura, if we can just possibly at the conclusion, just make sure that we have a separate link maybe to that video. And I can link that separately for everyone to have access to that as well. Great. And do you still hear me, Lindsay? My mic? Yeah. Do you still hear? Great. Great. Yes. My headset seems to be having a moment. So I apologize for that. I can hear you well. Great. Okay. We've gotten some good responses. I'll go ahead and end this poll and share those results. Yes. Ask security to escort nurses. Yes. Watch the situation. Add staff. And that's a good idea if you can definitely do that. This incident happened, and, of course, it was o-dark 30 when this incident happened. And this poor pharmacist is down there by herself. And so once they started to see, maybe this isn't such a great, safe area. And so that's why maybe we need to revisit it. So I'm going to start now with the conditions of anticipation. Those of you who've listened in the past, you know any facility that accepts Medicare or Medicaid must comply and meet all of the conditions and standards, everything that CMS has put out. And that's for all patients in all situations. So in November of 22, they did put out a memo that addressed workplace violence. And they do believe that health care workers also have a right to be able to work and provide care in a safe setting. It's not just applicable to patients. This applies to us as the care providers. Now, these requirements don't preclude health care workers from taking appropriate actions to protect themselves. In other words, if a health care provider is at risk or, you know, is being assaulted, they can take steps to protect and make sure they are safe also. There was a question that came up that said, wait a minute, I thought CMS said we couldn't have tasers or use weapons against patients. Well, that's in the actual application of restraints. But if they feel you're at threat of being harmed or are being harmed, then take steps to protect yourself. I also mentioned that, you know, leadership, we have to step up here. We have to make sure there's training and staffing levels so that people do feel safe. They're not there alone. Make sure that we have time to assess our patients for that aggressive behavior. And how do we adapt our environments and our interventions to make sure that everyone is still maintaining safe? Now, the regulatory obligations in safe care is at tag A0144. That's in the acute manual or appendix A. And what it's telling us is we need to look at those patients who are at risk, not only for intentional harm, but for harm to others. We also have to look at how is our environment? How is that set up? Is it a safe environment? And then education and training. And it's not just staff, but it's volunteers, because you may have volunteers who are taking patients to and from locations. Leadership is expected, or the hospital is expected to show how we identify those who are at risk for harm and then take steps to minimize it. We all know that we've done risk assessments, and yes, this does continue. And this is a patient risk assessment. Now, what strategies you want to use, that is up to you. They just have to be appropriate. For example, what you do in postpartum may be vastly different than in the emergency department or your behavioral health department. Access doors. Are you going to have security cameras? Great. Are they working? Parking lot. The structure, the lighting within that parking lot. Do you have security who can? Do you have enough security who can walk those staff members to their car? And then controlling the access points. You know, that example where pharmacy wasn't really, you know, that was kind of tucked in the corner in the basement. What about surgery? Who has access to surgery? Some of the recent studies have shown that those who do commit mass shootings will go to areas where there's a large number of people. Doesn't matter if it's a grocery store or a hospital waiting room. I did include in here a couple items from CDC. They have risk assessment tools for violence and there's additional resources where they include checklists, OSHA guidelines, injury prevention. So they are trying to help us out with this. I also talk about emergency preparedness during this program because it really must be based on and include that assessment, whether it's your facility assessment or community-based assessment. They talk about that all hazards approach. Last week we did talk about emergency preparedness and part of that all hazards approach is, you know, those that are man-made. In other words, our active shooter. We have to have strategies so we address those events that we identify as a risk assessment. What is your patient population? Who's at risk? It doesn't have to be just behavioral health. You can have a family member or a very large family that is very upset because their loved one has been injured. When I worked in San Diego at a hospital, it was a university-based hospital, and in the emergency room and the ICU, we had to separate when we had gang members who would come in. We had to separate them across the whole unit, maybe on different units, especially ICU or CCU, just because of the threat of violence that might have been posed. So they did do a good job in that respect. And then education and training. What are our patients? Who are at risk? What are the safety risk factors in our environment? And then strategies. What do you want to tell your staff when something like that happens? This includes not only those you employ, but our contracted, our per diem, our agency nurses, and volunteers. And of course, we have to have those policy and procedures to protect our patients, but also our workforce. As far as how and when, you decide how you're going to tailor based upon your patient population. Now, CMS does recommend ongoing every two years after the initial, in other words, after their orientation. So they do expect it during orientation. And any time you update your policy and procedures, what's going to be different? Maybe there's a different access point or a different way that folks would contact the emergency preparedness plan. Now, they do have a couple of citations where we did not meet these obligations. Here we had a nurse who was sexually assaulted by a behavioral health patient. It took another patient to intervene to stop it. Patient died. Now, this is a little different focus here. Hospital staff and law enforcement, they did a takedown and a custodian held the patient down on the floor, put the knee against the back and patient went apneic on them. And then we also have the patient who acted out, shot in the room by an off-duty police officer. Well, the staff here didn't perform an appropriate assessment with the patient and do that de-escalation to help bring that patient down. Now, normally at this point, I would run this YouTube video. This is a training video. It is on the CMS website under workplace violence. It was provided by Baylor Scott and White from Texas. I would normally run it, but I have a feeling that the audio also is not working. Now, I can run it because it does have underneath some of the, you know, what are the pointers here? What do you want to look at? So, Lindsay, what would you like me to do? There's no real talking other than what the shooter is saying. Yeah, let's try it and see here. Okay. So as you can see through that video, and I'm sorry again that the audio did not work, but that's how you would do it. That's just a very good training video. Again, if you're looking to start your program, go into the CMS website and download that one because it's free and it's available. Okay, joint commission. They've done a lot. To me, they've done a lot more than what CMS has done as far as workplace violence. They add in here the definition. So think policy and procedures. You can throw that into your policy and procedure. Of course, that's anything that occurs at the workplace. And it's not just physical aggression. It can be nonverbal. It can be intimidation, harassment. They put bullying into this definition along with other forms of violence. Then sexual harassment, sabotage, which I thought was kind of interesting. Anything that really involves staff, practitioners, patients, or visitors. So it's a very, very broad definition. They also added additional and they honed it down a bit more to physical and sexual abuse, intentional mistreatment of someone that can cause injury, sexual abuse, intentional mistreatment of a sexual nature. And it can be psychological. It doesn't have to be actual physical conduct. It can be coercion that leads to this event. And the reason they're putting this together is they do recognize it's a high incidence. And that's why they put the new requirements into place. And it will help with a framework in developing your systems. Again, they are really strong on leadership oversight, making sure we have those reporting systems, pulling together the data, analyzing it. And they go as far as, okay, what are you gonna do after the fact? That post-incident strategy, training, education. You know, we don't wanna have over-training of our staff to where they're starting to not follow it or really gain from it. And so that's why they do recognize still training is so critical. So here are the applicable standards that we're gonna cover. Environmental care, our human resources, and of course, leadership. I'm gonna start with environmental care because that's everywhere. And really you have to manage safety and security risk. And really know these risk effects. Everyone, doesn't have to be just a staff, it can be patients. As you saw there, that happened to be a very disgruntled husband who was seeking out his spouse. So it can be against a staff, it can be a visitor or a patient. Safety risk, that's the physical environment, something that's beyond your control. But security, we can control because these risks are usually intentional. It can be, again, workplace violence, can be infant abduction, can be theft. So they kind of clump all those three together. That's why we need to put together a safety and security risk assessment and associate that with your environment of care. Now, these are the risks identified from internal sources. It can also be your RCAs. You can do an RCA and realize, hey, this is what happened, take that information. Maybe you've got a level one emergency trauma, again, increased gang activity. You have an oncology unit, terminal patients, and the families are upset or at ritz end or just so despondent over what's going on. I have a sister who worked at a hospital here in Boulder, Colorado, and they had a patient just like that. Patient was on oncology and the daughter who was taking care of her came in and killed her, shot her, and then ended her own life. So it's not just the ED. And of course, maternal fetal. We might have domestic violence issues that can crop up. So what we have to do is identify those who come into our facilities and determine, do we require identification and how are you gonna do it? Badging, remember that one photo I showed you from 2017, that door hadn't been locked. Anyone could come in and out. Well, since that incident, they now have locked all external doors with the exception of the front door. And now people who go in through those ancillary doors have to badge in and out. We control the access. Those who are identified as a security sensitive, door alarms on OB, pharmacy, definitely wanna have those. Maybe you wanna have security at that door. Are you going to arm your security? That's your decision. You have to make that decision. Do you want them armed? And this brings me to part number two of our situation. So what do we wanna recommend that the hospital assess? Remember the first one was, hey, is this a problem? So then we have the assessment. Lindsay, I'll leave it to you on how you wanna put that question to the attendees. Yep, absolutely. I have that up there now on the screen. So you should see several options here available to you. And as I just said, so what would you recommend the hospital assess in your options here? Review all incidents involving the pharmacy, review local law enforcement events, what occurred in the area, physical location of the pharmacy, staffing, is increased staffing reasonable? And then number of times nurses had to retrieve additional medications. And if you have any additional comments here, maybe for your selection, you can type that into the chat as well. And especially if you have more than one idea, perhaps you've instituted some of these that have been very beneficial and your other colleagues could learn or gain from your experience with them. Because I recognize sometimes staffing is, trying to increase staff may not be possible. That's totally understandable. But yet if you can, did it work? Did that help? Or have you found that staff is more comfortable in completing and coming to work? I see some good responses in here. A couple still coming in. Give me just a second. Okay, here we go. Go ahead and end this poll here and share this results. Great, all right. Yeah, I like, especially review those incidents. That's always a great place to start. And also how many times did the nurses have to go down and get that? Why is that happening? Is it because just staffing issues in pharmacy or other items? So really those are very good assessment starting points. Now there is, they put out a new requirement, number 17. This is again, joint commission, where you have to conduct an annual analysis related to your prevention program. So again, annual. Take actions to mitigate, maybe resolve. Look at any of those safety or security risk based upon that finding. Ask the staff, what worries you when you come into work? Is it walking from the parking area into the hospital? Is it working nights, evenings, holidays, whatever it happens to be? What makes you nervous? So as far as your work site analysis, here are the requirements. One, of course, it has to be proactive. You have to investigate the incidents if and when they do occur. Look at your program itself. How often have you looked at those policy and procedures? Are they even relevant? Or do they need to be reviewed and updated? How about our training and education program? How often are we doing that? What are we using for our education and training? What's our environment set up like? And by the way, I do wanna mention on education and training, some hospitals have actually reached out to law enforcement to come in and help those who do respond to these active shooters because they can really give some good information and it helps establish that liaison and communication tool with law enforcement because then law enforcement can also see what's the setup in your hospital. If they have to respond, they know. They can give you pointers on where are your weak points. Does your program, does it really reflect what's going on? Best practices, any laws or regulations for your particular state? Take this information that you're doing to monitor your environment. What are the safety factors? Is it unit specific location? Maybe you have a couple offsite areas that really make you worried. Maybe you have an offsite radiology or chemotherapy or radiation for cancer that is starting to make you nervous just because patients and their families can react. And then also we have to monitor, report and investigate. Now they did add a few items in here, Joint Commission did. So the hospital, you have to have a way to continually monitor, internally report and investigate. And this is a wide ranging reporting. Injuries to patients, others within the facility that could be visitors or staff. Look at your occupational illnesses and injuries. They may not have been injured but they're still calling in sick because of the psychological trauma that they experienced. Safety was added to this, safety and security incidents. And then including those related to workplace violence. Again, that's new as of this year. Any hazardous materials that were involved, fire, safety, medical and lab equipment. Again, all of this happens to do with what you have to internally report. Now there are two notes included and that's just how they put it at the bottom. Those of you who've read the Joint Commission requirements, they have notes at the bottom. So all incidents and issues, they need to go to QAPI. They do. Maybe you have a reduction team or a reduction effort when you have these incidents reported. They need to know what's going on. Share them with those who are designated to coordinate your safety. That could be your safety manager. Could be maybe someone in security. There has been some discussion within the Ashram listserv. Who manages your workplace violence? Who is responsible? You may want two or three people. You may want someone from leadership, head of security. Maybe nursing can be involved in that because they are having that actual patient interaction. The incident reports, you may have to consult with your legal to preserve confidentiality, especially when it does involve a patient. Now, of course, we don't want this to block any opportunities we have to make changes. We don't. We just have to sanitize the information. So that's why you want to work with it. Some companies, some hospitals have developed their safety risk team, where they take all of these incidences and evaluate them and then help the staff address how are they going to respond to patients. We saw a lot of this at Kaiser with some of our outpatient situations and it was a really huge benefit that they had a team that could work with that particular service in helping to deescalate and work and continue to work with the patient and or family so we could keep them and continue to provide care. So as far as why are we collecting data? Well, it helps us identify what's going on and where are our vulnerable areas. How can we put environmental controls in place and education? You know, staff has to know where's the alarm button if they're going to activate it. Data collection can also help see trends, patterns. Are there gaps in our programs? Or is the program actually working? And we just want to keep it going. And also, is it affordable? That's one other thing we want to keep in mind. So as far as the reports and investigations, this is where it could get a little challenging because what you're doing is you're taking the information you get from the reports and then you're investigating it, whether it's patients, staff, others within the facility who are causing this. And again, that includes workplace violence, which is new. And I say it's challenging because sometimes staff don't want to report it. It's like, oh, they were just having a bad day. Or it's like, oh, they were very, very sick and they didn't know what they were doing, okay? I understand that. Most of us who've done bedside care, we know that, we've experienced it. But yet we have to be able to protect our staff. So how are we going to do this? We know it's under-reported, but it's still a major problem. As you start to adopt standards, to collect and report data, you can start to benchmark it. Is it working? Is what we're putting into place working? Or do we need to modify that? You know, it may be that if you have a patient who's very ill and is throwing punches, maybe there's an additional person. It doesn't have to be all our in-staff. Maybe an additional clinical person who can help stand by and calm the patient or, you know, hold their hand so that they can't slap or hurt your nurses. The next major area is human resources. And they say here, we have to have ongoing education and training as part of our prevention program. That has to have IR. Now they say annually, and of course, whenever changes do occur. If you're doing your annual skills level and schedules skills lab, good place to start it. I can't tell you how many times you have to reiterate to the staff. This is really to help you stay safe. Leadership includes our practitioners also, volunteers or contractors. Now, who's going to respond if something does happen? You determine how you're going to do that based upon this person's role. What are their duties, their responsibilities? How are we going to prevent it? How do we recognize it? Do the hairs kind of go up on the back of your neck when somebody walks in and maybe they're dressed like that. By the way, this individual, there was a weapon in his backpack and you can barely see it, but in his right hand, he is carrying a weapon in that right hand. And this was caught on the security video. How are we going to respond and then report these workplace violence issues? So that has to be part of our education and training. And again, what constitutes violence? Also training for non-physical intervention, calming them down, walking away, locking yourself in a room. De-escalation. Now, de-escalation, it's not required under CMS, but you might want to look at it because it can help prevent bad things from happening. And then of course, if you do have to respond physically, okay, what are the safest intervention skills? And of course, the incident reporting. When there is an event, definitely fill out an incident report. And you ask why? Because was there a patient injury? Was there injury to staff? You definitely want to keep track of these to find out how did this occur? How did it get so far? Because by identifying what does constitute violence, well, that's an awareness of what are the physical and non-physical acts. Of course, we know physical, hitting, shoving. Non-physical, you know, yelling. Racial slurs, that's not okay. Even bullying, you know, when a patient's family comes up, gets in your face and starts screaming at you or at your staff, we need to intervene. Don't care what's going on, it's time to intervene. Threats, whether it's in-person threats or a phone call. Again, tell your staff, this is critical. We need to stop this. And of course, de-escalation intervention techniques. Joint commission has what they call these quick safety. It's like a little memo that comes out. And number 47 talks about de-escalation. And it talks about recognizing what is aggression and some of the models to try and defuse it. So I've got the link there that you can download it. Now I've gone back in and I checked a week ago, this has not been updated. This is pretty, pretty common information. There's no brand new technique or lightning rod sort of information that came down and told us different. So it's a really good place to start. And of course, put your prevention tools in place. Simple, accessible reporting process. Because what we're trying to do is reduce that likelihood that your staff is going to be a victim of workplace violence. That's why I suggest you might wanna look at outside sources for training. Law enforcement. There are companies that do this also that can really give some great pointers. They can come in and see it. That's what they're trained to do. Some of these folks have gone through extensive training to identify, here's your weak points. And here's the areas where you're real strong and keep it up. Let's now expand it to another unit. The third area Joint Commission really hounds in on is leadership. Because we know they create the culture that includes the culture of safety throughout the hospital. And it talks in the rationale about, this includes behavior that intimidates others. When you have a staff person, I don't care if it's a physician, a PA, a nurse, whoever, that is not working well with their colleagues and intimidates them. Well, that's included and that's not okay. Because that affects your morale. The lower the morale, the higher their turnover. And really undermines that culture of safety overall. Because if they're not wanting to come to work or they're scared, they're not gonna do things either. You have a workplace violence program. It is led by a designated individual. You can have more than one, that's your call. But it is put together by a multidisciplinary team. And this team, because one person can't do this all by themselves, they have to help with the policy and procedures. They have to help and encourage that reporting incident reports and analyze those reports. Who's gonna do that? Will it be the security team? Will it be risk management? Will it be your patient safety team? Who's going to evaluate those? How are you going to follow up and support? Not just the victims, but those who witness it, that can also impact them. And that these incidents really need to go to the governing body. Because they have to know, they have to recognize. Because identifying, having someone accountable, first off, make sure we have, who's the clear line of authority? Who are we going to go to when something's not working? And then how are we gonna follow up with these events? It decreases that variation in your program. So what worked yesterday is going to work a week down the road. The data collection, please make it easy and accessible for those to report. It does show that we are committed to keeping everyone safe. And regular reporting, these need to go to the governing body. They have to be aware of what's out there. And also accountability for the program. If the governing body knows, this is where we have a weak point. Maybe there's this back area where we had this incident where during high weather and hot weather in particular, the ventilation system was pushing out air so hard, it popped open one of the security doors. Yes, I know that sounds strange, but it actually did happen because we went to observe it. And so what we had to do was by seeing this, okay, now we know who we have to go talk to to get this thing fixed. It could be just something as simple as that. Again, we had that accountability for the program to make sure things were getting done. So here's part three of our scenario. Lindsay, do you want to go ahead and just read this? If I can get off of mute there, I can. Okay. This is Saturday night. The hospital was quiet. The pharmacy tech had to run an IV antibiotic to the OR, leaving the pharmacist alone. Upon the tech's return to the pharmacy, he was approached by a knife-wielding man who forced his way into the pharmacy, threatening harm unless the pharmacist handed over fentanyl and oxycodone. Security responded when the event was observed on the security cameras. The pharmacist refused the demand, and the assailant cut the tech's throat, non-lethal, and pharmacist's arm. Security entered the pharmacy and subdued the assailant. And then here are some suggested measures. And I don't think I have this one up as a polling question, Laura. Yeah, that's okay. And again, folks can just add into the chat if they so wish. So really, with this particular situation, how are we going to handle this? Who are we going to respond? Was it handled appropriately? Did we appropriately address it in that situation? Pharmacist was alone down there, and this assailant entered, okay? How did we do that? How did that happen? Policy, procedures, they defied to come back and have the zero tolerance for violence. Doesn't matter who it's coming from, whether it's from family or an outsider or could be staff. And then what do you do? Encourage that reporting and again, support them when it does happen. I've never had the opportunity, thank goodness, to observe workplace violence, with the exception of a patient who happened to be yelling at one of my techs where we were able to intervene right away. But the physical violence, something of that magnitude with the pharmacist, no, we didn't have to have. I haven't experienced that. But I can imagine that would be very traumatic for someone, especially trying to go back to work after that. So policy and procedure development. Use that definition of a workplace violence that joint commission had. It's there and it's pretty thorough. Maybe you want to include assault and abuse definitions. How are you going to resolve those definitions? In other words, would you include a patient's brief but intentional brushing or touching of a staff member's buttocks as assault? How far do you want to go with those definitions? What type of events do you want to include? Now, of course, the old legalese comes in and says it includes and it's not all inclusive of, but what are the common ones you're seeing? That could be through your incident reports, staff reports. And how are you going to address those events? So this has to be part of your policy and procedure. Those of you who are joint commission, are you going to consider this a sentinel event? If you look at their definition, which they updated I think two years ago, it's not, this is one not naturally related to their course of illness or condition that reaches a patient and results. Now, are you going to add this for your staff where a staff member has been assaulted and has been injured? And if so, determine if you want to add that to your sentinel event policy. If so, then you have to do your RCA or RCA squared, whichever process that you're having to utilize. You may want to include it as one to show staff, hey, we're concerned about your safety and we want to take care of you also. It's not just a patient. Again, are you going to include where a patient grabs a staff member's arm and just grips it real tight as assault or not? There are posters, check to see if these are permitted within your state or by your hospital policy. Now this just happens to be one that I did find. They put it up and they just noticed such an increase. Don't forget other languages that you want to include this. Maybe in those top three languages, again, it's not required. It's not one of those required signs, but you may want to do that. Communicate to the staff so they see it. What is the perception by the patients? Maybe you just want to ask a patient, how do you feel about this, this aggressive behavior? And then how are you going to define aggressive behavior? Is it one where I have been waiting in this waiting room for four hours and no one's come to see me and they're yelling at the staff? Is that considered aggressive behavior or is it one where they're up there grabbing on and slapping their hands on the desk? What constitutes aggressive behavior? Let's go back to hospital and just think about him for a minute. Now what? What should they do in this situation? Let's say if they want to just type whatever they want into the chat, that's fine. Do they look at the assessment? Did they even do one? Do they get staff provide that emotional and physical support for them? Remember the one staff member got cut. More security cameras. This place, again, the pharmacy was literally down in the basement in the back. Great. By the time security sees this, can they get there in time? Tighter controls for access after hours. Anything else that perhaps hospital aid can or should do? And I'm going to break for a minute, Lindsay, and see if there's any questions at this point. Okay, perfect. I don't see any pending questions at this time, but just a quick reminder, we are almost an hour into the session. So if you have any questions for Laura, go ahead and type those into the Q&A option there at the bottom of your Zoom window. Or if you don't see that option, you can, of course, type them into a chat. I do just see here is a comment to your previous slides come back that's in areas with large lobbies. It is not uncommon that air pressure during certain atmospheric change can pop up in a door. Technically, the door does not fully latch, and it's often accompanied by a whistling sound. Absolutely. Good. Yeah. The one door in particular, that was an outside staff-only entrance. And where it was located was next to an open space. And many of the unhoused were staying in that open space. And so that's why it posed a huge security risk for them that, you know, we could stand there and the air conditioner would go on, there goes the door. So yeah. One other thing I want to comment on while we're waiting here, emergency department doors. And it has come up where, okay, this is a security risk to have those emergency doors unlocked, especially at night, where we don't know what's going to come in. That could happen anyway. Can we lock our emergency room doors? Well, at CMS, I haven't heard back from them yet. But some hospitals, they've been able to, they have a camera there, and there's a security guard posted there to, you know, let the person in. And it's kind of an anti-waiting room, so to speak, that they can wait there. And then a clinical person comes down and does that assessment. Because a security guard can't do the assessment, that MSC, to determine is this an emergency. But at least the person is, they're coming in, they presented to the emergency department, and help is there if they need to secure that door. In other words, keep your staff in everyone's state. So that's one item that you can look at. But I am still waiting for confirmation from CMS. Is that an acceptable alternative for safety, and also to maintain the requirements under EMTALA? Perfect. I don't see any pending questions at this time. Okay. Okay. So as far as what they need to do, yeah, they definitely, I'm going to back up, excuse me, they definitely need to look at the assessment. One hadn't been done for some time. It had been quite a while. And they did the support, and then they did tighten the controls, make sure that no one could get down to the pharmacy area. They had to go through two locked doors in order, well, they had to go through one locked door to get to the pharmacy door in order to keep it safe. I mentioned we're going to talk OSHA, and also the Department of Labor. They have put out now guidelines on preventing workplace violence in healthcare facilities. So I've got the link here for you. 44 pages, it's, and they even have great examples from other healthcare systems. There is no one standard that OSHA has put out on this one. But as an employer, yes, we are, we have to have a place of employment free from recognized hazards that can cause harm or even death. And workplace violence is one of those recognized harms. They have five core elements or building blocks for any particular plan. Management's commitment and employee participation, analysis of your workplace, looking at those hazards, identifying, putting together a prevention and control for those hazards, training on health and safety, and keeping records and looking at the program itself. It's very similar to that Plan, Do, Study, Act that we've heard about. So as far as management commitment, they know it's critical for that success and importance to show that this behavior is unacceptable. And there will be consequences of that behavior. Has that environment of trust that these are opportunities to learn? We know that. And that's why we're doing this continuous improvement, the QAPI. So what can management do? What is within their purview? Well, of course, they can develop and post these policies in areas, make sure they're up there. This is our statement. And this is our position, that one poster that I showed you. Any acts of violence against staff, visitor, others will be handled immediately, and including law enforcement involvement. They have to be involved, have to be visible, that the staff know, please report this, please. Now, some staff have said, well, great, we reported it, nothing gets done. Well, tell them what is being done. This is what we've done. We've taken a suggestion that one of your co-workers has put out. This is what we put into place. Regular meetings help, because number one, it gives you visibility, but also perhaps that opportunity for questions and answers. These are going to be hard questions, and management needs to be able to address them. Have employee involvement in the decisions. It's one thing for the C-suite to put these plans into place, but if it's not workable, the employees won't do it. That's why having their involvement, they're saying it. What can you, what do you see we could do in this situation? And make sure it's done timely, that they just don't wait and hold on to it, follow up when it does take time. Some of this may involve construction, where, hey, we have to build new walls, or we have to put in these security doors. Yes, you have to carry your badge with you. That is a requirement. Then the next step is looking at our work site and looking at the identification. What could contribute to violence? Is it unrestricted movement, your main doors, parking lots, and poorly lit parking lots in particular? I don't know about you, but I don't think I'd want to go into that parking lot walking from my car to the hospital any time of day, as poorly lit as that is. Look at the records, employee input, what were the injury reports, and where are they occurring? Is it a time of day? Is it a shift? Is it a location, a unit? Patient input can help, you know, just talking to them, maybe even visitors. How do you feel when you walk into our hospital? Do you feel safe and secure when you're in here? You may not like the answer, but it's a good way to collect some data. And just walk around. What do you see when you walk around? Are there hidden corners? Are there blind corners that staff may not be able to see? And of course, then we have our prevention and control. Starting with our engineering, you saw that parking structure. Add lights, make sure the lights are working. Controlling access and other security technologies. Administrative workplace controls, staffing, and training. That's really what they're talking about here. Fourth step, safety and health training. Who gets trained? Pretty much everyone on your staff really needs to be trained in this. And they have to recognize this, of course, according to what their role and responsibility are. Are you going to do classroom, hands-on, you know, that safety training that you do once a year? Are you going to do it just in time? You know, something's happened. Okay, let's go back and visit this. Do that review, that after event action report. And then look at your training. Is it current or do we need to update it? Maybe bring in new techniques. They always talk about record keeping and program evaluation, keeping accurate records and identifying those trends. So, where do we need to train? And of course, methods of our hazard control. Did that door actually work? So, what are you going to do if the power goes down? Right now, some of the states, Texas in particular, is facing the outcome and the results of Burl. All right, is your backup generator, are they able to power your security systems? Record keeping, now OSHA does have certain requirements that we do have to report, keep records on. Of course, death, anything that would restrict work. Do they have to have medical treatment, loss of consciousness or serious injuries? Do we have to transfer a patient to a higher level care or an individual? And again, that's OSHA regulation. And then look at our reports. Have a uniform definition of what is an injury and how did it occur? So, that's, they also have other guideline publications on workplace violence. These are free and they even have some really good checklists that you can download. There's more details, resources and workplace assessments that you can put into here. So, OSHA has done a lot to help us, which you would expect from OSHA. Department of Labor, they also give us some information on what's available. And there's one other resource and that happens to be, it's called ACES, and that's American Society for Industrial Security. They have checklists that you can download. They're free, that you can pull them into place. They also address workplace violence and how you're going to respond to them. Now, fortunately, they did have a checklist also with behaviors. I know, okay, how is this person going to escalate? I like it because they did have quite a bit. What do you do during that threat response? And how are you going to, what are you going to do if it becomes violent or threatening behavior is observed that it poses an immediate, immediate danger? So, again, that's ACES that you can download. And then finally, I do want to talk about, again, Joint Commission. They do, they've added much more in their emergency response. Now, this is not a video, but I want to show you. Yes, this happened 12 years ago, but for those of us who live in Colorado, it was like it was yesterday, unfortunately. We had an individual, very ill from behavioral health, and he entered a theater late at night and opened fire. He came in through an unsecured door in the back of the theater. It actually had been propped open for ventilation, which was against their rules, and multiple people were killed. And they were a hospital that was nearby. It was only, I believe, a level three trauma. But what you can see is the emergency response. They activated their emergency preparedness program. It was all hands on deck, even though it was about midnight, and they called an extra staff. And they were able to coordinate how they were going to respond once these came in. Staff were pulled off floors, and they went out with stretchers, because people were simply being brought by cars, personal cars, in order to get to the hospital and respond again. This is one of those where it was a man-made emergency. Now, their standards don't mention violence. They don't, but you want to consider it when you, and if, you have to reactivate your response program. This follows the conditions of participation, and it includes that comprehensive program on an all-hazards approach. So that's why you might want to consider using a community mass shooting event for practice, to be prepared for it, because you do have to do a vulnerability analysis using that all-hazards approach. What's the worst that could happen, and how are you going to respond if it does occur? Have that operations plan based upon that approach. How are you going to communicate? You know, what is your warning system to your staff and those who are off duty? Maybe you've got other hospitals with your emergency response. How are you going to tap into it? The Aurora Hospital did contact our level one trauma and our children's hospital, which was based next door to our university hospital here. Now, fortunately, there was only one or two that did have to be transferred to the higher level of care for children's, and one or two to the level one trauma, but otherwise, of all of those people, and they were in the 20s, that were able to stay within that hospital, and they managed it well. That includes safety drills as part of your plan, and again, you might want to consider notifying your staff that this drill is going to occur, because it will freak them out. I've had an emergency preparedness group that I had contacted on how do they do this when they go in, and that's one of the things they tell their staff. Let them know this is a drill, because again, they did this here. When your folks, when the law enforcement show up, they are not going to help you. They are not going to help your patients. They will step over your patients. They will push you aside to get to the perpetrator, so just make sure your staff are aware that that could occur. Also, if you see SWAT teams and police surrounding your hospital, it's a drill. Take it seriously, but know it's a drill, because when this hospital that did do it, again, a level one trauma, the staff were very, very upset because they were not aware it was simply a drill. Now, they wanted that honest reaction, but it kind of backfired on them in order to do that. So unfortunately, with not being able to use my videos, I do have some takeaways. So we're well ahead of schedule today, Lindsay. Look at your plan. First off, who's going to own it? Who's going to be responsible and accountable to it? Again, you decide is it going to be your head of your security? Is it going to be your plant manager? Who? Include staff in development because they know what the risks are out there. They've worked in those rooms. They've been in those hallways. They know what's out there, and they know patience. Support the staff. Please get them to report and make sure you circle back with them so they know what's been done or what's being done so they just don't think it's falling on deaf ears. In your policies, be clear on what constitutes that workplace violence and that is communicated to everyone. That includes contracted staff. That includes contractors because if you have contractors working in your building and they're harassing your staff, that needs to be addressed because that's not okay. Other resources, whether it's equipment, personnel, whoever that happens to be, that could be your security. Again, we've had cameras that, yes, they were in the parking lot. Yes, they were in the parking structure, but they didn't work. It doesn't help to have it if it doesn't work, and someone needs to man it and know what to do if they see something. Training, the responsibilities for those. Again, maybe you want to have that outside expert come in and drills. FBI also has some good training that you can tap into, but again, you might want to consider warning staff when this is going to occur and have the support for your staff because that can be terribly, terribly upsetting. There are additional resources. Lindsay, I'd be happy to provide those after the fact on resources for staff after an event because, again, we need to take care of them. Then don't forget your assessments. Walk around. Talk to staff. What concerns them when you come in? Have you experienced or been exposed to any of that? Again, communicate with them so that we can improve safety. I was doing a program a couple years ago, and I had the director of safety there at the Aurora Theater, and he was going through talking about it. Unfortunately, there was a participant in the audience who he and his wife happened to have been mugged at gunpoint two weeks prior to this program, and it triggered them. So kind of keep that in the back of your mind that this could trigger something in your staff with those drills so that we can prepare. So here's my last one. Again, done well ahead of time. We have a level two trauma, large urban area, gang violence increased. Frequent episodes that are coming up near this hospital. They've increased security, but here we had a gang member who came into the department to find and kill a rival gang member who was there for treatment. The inter-gang member struck a nurse and PA trying to get away. The shooter fired several shots, wounding a physician before being shot and killed by the law enforcement. So what advice, if any, can you give to D to manage these future events? And I've just got some suggestions here that I'll let you choose from. Do they put more security in the ED? Checking everyone. And then, okay, I'll let you, here's the option. So that's great. Do they put in metal detectors? Do they use guard dogs? That's always a question. Do they lock the E doors? I talked about that. Do you lock the ED doors? Risk assessment, train staff on self-defense, armed security, tasers, guns, weapons, arm the staff. Anything else that you can suggest for our hospital? And again, this, I always try to take the events that happen in my state, not anybody else's state, and I'll tell you what this hospital did end up doing. So again, folks, we're done way early today. So I apologize that the video was not able to provide any audio, but it will be available to you once Lindsay posts the slides. Yeah, absolutely. And we may have to do the link to the video separately, Laura, outside of the slides. Yes. So you can send that to me. We'll make sure everybody has that. Okay. I'm scrolling back through. There are a couple of questions. I see some of you are still putting in responses here to the final discussion. So I'll give you just another couple of seconds there, and we'll come back to that. And while we wait, I will go ahead and address some of these questions here in the chat. And this first one says, did you say that CMS does not require annual de-escalation training for hospitals? No, they require training. What you include in there, whether it's de-escalation, is up to you. They also don't, they, CMS does not require that. I always call them after action report or kind of where you do a debrief. That's a magic word. They don't require a debrief, but you may want to do de-escalation because in patient safety and for, for patients, when you have a patient who is having a psych, I want to call a psychotic episode, but they're starting to act out, you try to de-escalate, but that's just part of normal nursing care that you want to consider for that. In workplace violence, where you have somebody who's coming in with a gun, that's a different situation. I would simply add it. So you cover all your bases with CMS. Now, as far as de-escalation, again, if someone's coming in with a gun, my idea of de-escalation is I'm going to do the run and hide. Okay. Let's see. This question says as costs rise and hospital reimbursements decline, many departments, including security are being challenged to accomplish more with fewer staff members. How can we ensure workplace safety while also striving to cut expenses? Do you have the magic answer to that? I wish I did. No, I think that's where leadership has to really, really focus. There was one system where one of the staff complained, why are they building a brand new wing and I can't get enough nurses to stack my unit? And that's got to be the leadership decision because that's what it's going to boil down to. What is leadership fine? That's part of their requirements for a plan and budget to meet the needs. They have to do that as a governing body. And they also have to make sure it's a safe and secure location. If the reports, your assessment, your reports, your analysis saying, if I had had another person here, it is very likely this never would have occurred. One more person. And I get it. That's a problem we're all facing. That's just not good. I wish I had that magic bullet. No pun intended. Okay. And then there's a question here asking, could you review the de-escalation training options again? I would have to back up the slides. I mean, as far as de-escalation, are you talking joint commission? I'm not sure, Laura. Yeah. Yeah. This question came in from Laura. So if you have a more specific thing that you're looking for there, possibly let us know here in the chat. Otherwise you will definitely get a link to the slides and I'll go ahead and provide that there for you. Get in the chat so you can have it now. So you can go back and review that as well. And also this, again, is a few moments, but if you have additional questions, or maybe it's just something specific to your organization after looking back at the slides, I know Laura would be happy to answer questions following the presentation as well. So you can always reach out after we conclude today. Okay. Let's see. Yeah. This event actually happened at a hospital that I worked at. The rival gang member killed my patient in front of me. It was traumatic. I'm so sorry, Deborah. That is awful. Yeah. That's how they say, Oh, you should be able to handle that. No, that's horrible. Absolutely. So sorry about that. Okay. Yep. We have done several of these. We have armed and unarmed staff, threat detectors, including metal detectors. We lock certain doors and the only entry is through the ER. Okay. Yep. And as far as arming staff, check again, that's why I always say work with your counsel, because your staff may be allowed a concealed carry. Some states do permit that where you have concealed carry, they have to have usually a license or a permit to do so. So you may want to think about that. And also, how is that going to be secured when they're not carrying it? You know, if you tuck it in the back belt, those folks are pretty good about getting ahold of it. So that's how are you going to do that? We had, we had one surgeon we had to work with because he wanted to carry his pistol into surgery with him. And it was somewhat of a challenge. That's probably not the best idea to carry a pistol. What if it drops and hurt somebody? And why do you have to have a pistol in surgery? I mean, if you're not getting along with your staff, that's a different story. But let's not take the weapon into surgery. Does your state permit concealed carry? Do your hospital policies permit concealed carry? I even worked in a building where I found out one of my co workers had a gun. And it's like, no, we just revisit that. And so we had to make sure that was either home or concealed in her car, because she was bringing it onto the premises. Not the person I wanted to have a loaded weapon around sometimes. Let's see. Okay, Laura, this came back in from her. She says, we have been trying to find resources to train our staff, but they are very expensive. She's just saying that she's not sure if there are better options for deescalation, CPI and others like that are out of their budget. Yeah. If there's a behavioral health unit, and you happen to have somebody who belongs to the American Psychiatric Association, the last I heard, they did have some good techniques for deescalation of a patient who's in crisis. One other thing, and your state may have started this, where the law enforcement has joined with the mental health services of the state. And they now have someone who goes with them or is available 24 seven to help law enforcement with the deescalation. So if they're called to a scene, and it's a question of domestic violence, or someone is just having a meltdown, they have that person that can go with them and calm and deescalate the person. It's been a huge benefit because they've been able to avoid officer-involved shootings with this option. So I would check with law enforcement, see if they know someone who they work with to deescalate any of these deescalation points that could be state or state funded, and therefore accessible to you. I got to hand it to Denver. They really stepped up because we've had some very unfortunate circumstances where deescalation would have made a huge difference, a completely different outcome. Great. And Casey says, therapeutic options is a budget-friendly option. And Heather says, we employ and partner with local police to be on site in the 80s during high volume periods as well, as if there is a community escalation of events. Okay. Let me go ahead and end this poll and share those results from that final discussion question. And then if you have any other final questions, y'all go ahead and type those in. Great. And on the police dog, there was a couple of hospitals who do utilize them because they found that's a huge deterrent, where they will see the police dog just kind of sitting there. And the reason they did it was because they found some of the gang initiations were go out and shoot and kill a police officer, law enforcement. But the dog is a different story. They see the dog and they'll take off. They'll say, no, nevermind. I'm going to leave. And the dogs were, they were well-trained. It wasn't an issue as far as injuries, unintentional injuries with that police dog. The only problem they had was trying to keep the kids away from going to pet little Rover thinking, oh, that's a therapy dog. No, that's a police dog. We can't be doing that. So I'm going to just flip through a couple more here while I, we've all done these. And so I wanted to show you, it's just some of these resources on the interpretive guidelines. They have a group that can help you with some of those interpretations, but otherwise I have information, the streaming videos, violence on the job there. That is, that's a long one. That is 21 minutes and a case study. There is transcripts. They have workplace health and safety for you. Again, I've tried to get all of these that are free FBI, active shooter response plan, and also NSO what to do the national nurses service organization. They do have what to do in an active shooter program. The last I heard that happened to be free because I had to use them for professional liability, but for everyone. Thank you. You get quite a bit back again. I apologize that the audio did not work. I will work with Lindsay. So it doesn't happen again and make sure you definitely have that video clip available for you. It's really nice. These are folks who have experienced that violence firsthand. They've been hit. They've been punched thrown against the wall. They've been injured and it helps. It's good. Also learning for sometimes leadership to hear this, that, Hey, this is what they go through and it's not fun. It can traumatize them for the rest of their lives. It really can. So I'm in closing. All I can do is stay, stay safe, please. So Lindsay, I'll turn it back to you. Perfect. Thank you so much, Laura. I do see one final question. It looks like you're asking if, uh, would locking the ad doors violate MTALA. That's yeah. And again, that's what I'm waiting to hear for sure, because we do have that. You've got some areas where it's not safe at night to leave those doors just open. Um, and so that's why some of the other, what I'm hearing from some of your colleagues is that they lock the door, but someone is constantly monitoring it or plan B, the one door is open and there's a buzzer that the person has to push. And then security will see him. Somebody will see him say, can I help you? And says, yeah, I'm here. And if it's like, I'm having a medical emergency, um, a clinical person has to go down and greet that so they can do that assessment. So it is not, they still have access because MTALA doesn't say it has to be, um, you know, you have to let them in right away, all everything. It just says they have to have access. And I think that's what it's going to boil down to is how does CMS interpret access to the ER? Um, is it yes, they're in there and we'll get them checked out with the understanding we have to keep, have to keep everyone safe too. So I'll be curious to see what they are saying, how the response goes. I was hoping to hear by now, but with the holiday, I'm sure it got delayed. Absolutely. Thank you so much, Lauren. Thank you for always being so thorough and following up and, and keeping a pulse on all of this information from CMS and other regulatory bodies. We greatly appreciate you doing that. Just seeing lots of great comments here in the chat, thanking you for this information and the resources that you've provided. If everyone would just scroll up a little bit there in the chat, you should see my final comments there just as a quick reminder that you should receive an email tomorrow morning. Just note that it does come from educationnoreplyatzoom.us. And so because it comes from that Zoom email, it very possibly could get called in like your spam quarantine junk folders. So if you don't see that in your inbox in the morning, I would encourage you to check those additional folders. If it's still not there and you would just like to go back and access the recording, you can just use that same Zoom link that you used to join today's live presentation to also access the recording. And just remember that the recording is available for 60 days from today's date. And we do have an additional security measure in place to protect Laura's intellectual property here. So you're going to click on that Zoom link, type in your information that will prompt an email to come to us for approval. We approve those requests very quickly once we validate them, but we ask that you give us one business day to do so. And then again, you'll have full access to the recording for 60 days from today's date. And then also included in that email tomorrow morning will be a link to the slides that Laura presented today. But I did go ahead and provide that link there for you in the chat to have as a resource now as well. And we will again make sure that you have a separate link to the video so you can watch that. And then if you are joining us as a member of the Georgia Hospital Association, please pay special attention to the final link in that email in the morning that will take you to a survey from today's presentation. And once you complete that survey, you will then receive information on the continuing education credits available. If you are joining us as a member of a partner state hospital association, please reach out to your contact within your hospital association so they can provide you any information regarding CEs that your state is offering as well. Okay, one other question came in here, Laura, that says when you say ED doors, are you meaning the main entry doors into lobby or the entry into the actual ED department? I'm assuming you mean the entry doors. The entry doors into the emergency department. Yeah, like from the outside coming in. That's where some of the issues had come up. That's what I was referencing. Can you lock those doors at night? You know, some hospitals are so busy, there's no way they could lock them. But some of the smaller hospitals, like our critical access hospitals, they've been locking their doors at night because security risk. They just couldn't take the chance. That's what I meant. Okay, I don't see any other pending questions. You do see Laura's contact information here on the screen. And as I mentioned earlier, she is a wonderful resource, and she goes above and beyond in answering additional questions. And we so thank you for that, Laura. If you do have any questions, though, you can always reach out to us at education at gha.org. And we'll be happy to get those questions over to Laura, and then follow up with you with her response. And then Laura, we just thank you so much for your time and all the information that you shared with us as always. And thank you all for joining us. And again, don't hesitate to reach out with any questions that you have. And we look forward to having you back with us for future sessions. And I hope you all have a wonderful afternoon, a wonderful week. Thank you so much, Laura. Thank you, everyone. Thank you, Lindsay. Bye-bye.

workplace violence

healthcare settings

patient safety

risk management

Laura Dixon

assaults on nurses

safety regulations

CMS guidelines

TJC requirements

de-escalation techniques

security measures

staff training