Two and a half years after a violent attack on Children’s Medical Group in Austin, pediatrician Tammy McConnell, DO, still can’t go down the side corridor of the office where the horrific shooting of her colleague Lindley Dodson, MD, took place.
On Jan. 26, 2021, a stranger entered Dr. McConnell's private practice and held Dr. Dodson and several employees hostage at gunpoint. The shooter later killed Dr. Dodson and then himself. She was 43.
“I wouldn’t have come back to work if there wasn’t [a violence prevention plan] in place, and as we’re looking for a new space, we look with a different set of eyes,” Dr. McConnell said.
As violence against health care workers climbs, so has lawmakers’ attention on the matter. Most recently, the 2023 Texas Legislature passed Senate Bill 240 by Sen. Donna Campbell, MD (R-New Braunfels), requiring health care facilities to adopt workplace violence prevention plans by Sept. 1, 2024. The Texas Medical Association supported the bill, which, while not directly placing mandates on private-practice physicians, may involve them and other health care team members and employees in prevention planning.
Experts say the new law also presents an opportunity for practices to review their own safety protocols, as SB 240’s requirements build on existing regulations physician practices likely are already familiar with and subject to under HIPAA and Occupational Safety and Health Administration (OSHA) guidance.
The move comes as attacks against medical professionals grew by 67% between 2011 and 2018, with health professionals five times more likely to experience workplace violence than workers in all industries, according to the U.S. Bureau of Labor Statistics.
From anti-medicine sentiments during the COVID-19 pandemic to active shooter situations and patients disgruntled with health care costs, “there are so many determinants that are causing these issues, it’s very hard to get on top of them all,” said Joseph Valenti, MD, a Denton obstetrician-gynecologist and vice chair of the TMA Board of Trustees.
But workplace violence prevention in any setting should never be a write-off, he said.
“In an age where mass shootings are through the roof, every threat has to be taken seriously.”
Practices may adapt their safety protocols differently, and compliance often comes at a cost. But in this case, peace of mind is worthwhile, Dr. McConnell says.
“I can’t go back in time. I can’t get Lindley back. Someone who hasn’t been through a tragedy might not take [a threat] seriously, might overlook it. We’re just in a time, unfortunately, that if there’s a perceived or possible threat – take it seriously.”
Taking safety seriously
SB 240 is believed to be among the first government mandates, nationally or in Texas, for violence prevention in health care settings, says Heather Bettridge, TMA’s associate vice president of practice management services.
Under its General Duty Clause, OSHA requires employers to protect employees from serious hazards once they’re aware of them, she says. But official standards on how this applies to active workplace events in health care facilities are still underway; OSHA currently only offers guidelines to meet the general duty obligation (tma.tips/OSHAGuidelines).
A 2013 Texas law made assaulting emergency department personnel a felony, and 2023’s Senate Bill 840 by Royce West (D-Dallas), also supported by TMA, similarly escalated the charges for assaulting certain hospital staff.
But physicians and medical staff are vulnerable to hostility across specialties and facility types. Under SB 240, health care facilities must create workplace policies that include:
- Conducting at least annual education and training on violence prevention;
- Prescribing a system for responding to violent or potentially violent incidents at the facility;
- Addressing physical security and safety; and
- Adjusting patient care to the extent possible to prevent physicians or employees from providing services to a patient who has been physically abusive or threatening to them.
The health care facilities subject to SB 240 are:
- Home and community support services agencies,
- Licensed hospitals;
- Hospitals operated by a Texas state agency exempt from licensing;
- Licensed nursing facilities that employ at least two registered nurses;
- Licensed ambulatory surgical centers;
- Freestanding emergency medical care facilities; and
- Licensed psychiatric hospitals.
To create these policies, the bill requires health care facilities to “establish a workplace violence prevention committee or authorize an existing facility committee to develop the workplace violence prevention plan.” The committee must include at least “one registered nurse who provides direct care to patients of the facility” and at least “one facility employee who provides security services for the facility if any and if practicable.”
Facilities also must solicit physician input when developing and implementing the violence prevention plan, and physicians employed by such facilities are required to report incidents of workplace violence.
SB 240 as passed did not include a citation and penalty policy, but a violation could impact a facility’s licensure.
Katina Knowles, chief clinical officer for Advanced Pain Care, sees the bill as a chance to bolster existing policies.
“We had a workplace violence plan in place a while back, but reading [SB 240], I thought, ‘OK, we can tighten things up,’” she said.
Advanced Pain Care has 14 clinics, four ambulatory surgery centers, and a main office, and a wide array of safety protocols to match: an exposure hazard communication plan, an injury and illness plan, and a main emergency preparedness plan with 17 protocols.
The group started with generic safety plans, which Ms. Knowles and others then modified to meet the specific needs of their various sites. For HIPAA and other regulations, Ms. Knowles often conducts walk-throughs to observe any vulnerabilities or gaps. The same applies to physical security, she says.
And while SB 240 requires annual training, Ms. Knowles has found more frequent review beneficial.
“I don’t want to just have one [training] a year,” she said. “So, every month at staff meetings, they’re doing one of the drills. You’re not just hurrying through it and saying, ‘You’ve done your yearly, sign here.’ No, we really take these seriously. Nobody’s going to be completely prepared, but I want to give them everything they need in case something bad happens.”
Being proactive
If staff don’t know what procedure to follow in an active event, the resulting delay could be disastrous, Dr. Valenti adds. Having experienced delayed response from privately contracted security agencies, he says his practice has benefited from relationships with local police, who are more equipped to handle active events.
But just as physicians and health care workers may not be familiar with an active response, police may not be familiar with the needs of health care settings, so exchange of information both ways is crucial.
To that end, in 2018, the New England Journal of Medicine published a strategy co-authored in part by Texas physicians Kenneth Mattox, MD, and Alexander Eastman, MD, suggesting a new take on law enforcement’s default response. Whereas the “avoid-deny-defend” model that law enforcement typically recommends for most situations aims to remove individuals from dangerous areas and bar attackers from safe ones, this approach may require physicians to stop caring for patients in immediate need.
Instead, Drs. Mattox and Eastman propose a “secure-preserve-fight” model tailored to health care settings, which calls on first responders to focus on areas where essential, life-sustaining treatment is taking place. Medical personnel would cease nonessential care to move themselves and patients to safe areas, and fighting attackers would be a last resort only (tma.tips/SecurePreserveFight).
Incidents of aggression also can originate with the patients themselves.
“We’ve had a marked increase in patients both in the hospital and in the office being abusive to staff. That’s been really frightening,” Dr. Valenti said. “Patients are frustrated with their insurance and lack of coverage, not understanding that physicians don’t control their coverage and what’s covered and what’s not. So that usually gets taken out on the staff.”
But by and large, physicians who implement security measures are looking not just to mitigate violence but also to stop it before it begins. For Dr. Valenti, that involves a little strategic legwork.
“Women are at increased risk to face violence at the office and at home,” Dr. Valenti said. “Women, pregnant women, and children are some of the [groups] most vulnerable to violence and abuse.”
So, his office takes a proactive approach. For patients who visit the office with their partners, urine samples can be labeled with either a black or red marker. The red indicates to office staff and the physician that the patient needs an intervention for her safety.
“Frankly, it’s a safety issue not just for the patient but for our office staff,” he said, noting that a violent or disgruntled patient or guest can not only disrupt care but also pose risks to others.
It can feel excessive to monitor patient and guest behavior, and to respond to what could be minor complaints. But when it comes to patients’ and physicians’ lives, safe is always better than sorry, Dr. McConnell says.
Having had brushes with disgruntled patient family members herself, entry to her practice is strictly monitored and regulated for the peace of mind of her staff.
“We have cameras on the entire parking lot, and we have a camera on the front door, so nobody can enter without us visually confirming who it is and buzzing them in,” she said. “We basically have a locked down unit. That’s a different feel than just being able to come in, but I think it’s one everyone’s adjusted to.”
Taking additional steps toward security can impose a hassle factor for patients, Dr. McConnell acknowledges. But especially in light of her practice’s history, and because it keeps parents’ children safe, tightening office rules has gone smoothly.
“We have young families that aren’t aware of our tragedy, because we’re always getting new babies and some time has gone by, but we’ve never had any kind of pushback,” she said. “For [physicians] who are trying to consider that, if they’re worried about that, I would reassure them that we haven’t been met with any issues. And it’s not the most convenient. They have to buzz in, they’ve got a toddler in their arms. But it’s been pretty seamless for us in terms of our patients.”
Practices will need to examine solutions that are most appropriate not just for them but also for their budgets.
And Dr. Valenti warns that having a violence prevention plan won’t eliminate threats to physicians and their patients. But for the time being, a law like SB 240 “is a step in the right direction for sure. It’s just going to be a matter of how it’s enforced.”
Dr. McConnell acknowledges that while items like her practice’s security system are an added expense, and the burden of a mandate can be challenging, a security protocol “is a reasonable thing for us to protect our staff,” she said.
And it’s one type of mandate that Dr. McConnell says doesn’t detract from patient care. If anything, for survivors of trauma like her and her staff, it enables better work.
“You look over your shoulder more than you ever did before,” she said. “But patient care is the same once you’re in the room with the family. We’re doing what we love, and that part doesn’t feel different.”