The Compliance Divas Podcast
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The Compliance Divas Podcast
#160 Violent Incidents in the Dental Workplace - Are You Prepared?
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Someone Enters your practice who is hostile, angry, making threats and/or brandishing a weapon. What would you do? How can you prepare as a team for a potential situation like this? The Divas discuss recent incidents of workplace violence in dentistry and what every team needs to know to be prepared. It could save your life!
- OSHA General Duty Clause Letter of Interpretation https://bit.ly/3pwooic
- OSHA General Duty Clause Employer and Employee Responsibilities https://bit.ly/4dojf06
- OSHA Enforcement Procedures for Occupational Exposure to Workplace Violence https://bit.ly/44AQREa
- OSHA How to Plan for Workplace Emergencies and Evacuations https://bit.ly/3wpymWo
- CDC Types of Workplace Violence https://bit.ly/4drc5YV
- OSHA Guidelines for Preventing Workplace Violence for Healthcare and Social Service Workers https://bit.ly/3UOBLaU
- FEMA Poster: Be Prepared for an Active Shooter https://bit.ly/4dFXBVo
- OSHA Workplace Violence Prevention and Related Goals https://bit.ly/4b5Nwz3
Welcome. I'm Leslie Canum. I'm Mary Gavoni.
SPEAKER_02I'm Munda Harvey. I'm Olivia Wan. And together we are the Compliance Divas.
SPEAKER_03Hello, my name is Leslie Canum, and I'm your moderator today on the Compliance Divas podcast, where we're going to have a very special podcast that's applicable to every dental practice. We bring clarity and simplicity to compliance by navigating regulatory compliance to keep you on course. We recommend that you subscribe to the ComplianceDivas podcast through your favorite podcast channel or on our website, thecompliancedeevas.com. And the resources that we mentioned during our podcast, along with some additional resources, will be available on our podcast show notes. So you can click on the read resource and take you right to the documents that we're talking about. So today the topic is about workplace violence. Every year, thousands of American workers report having been victims of workplace violence. In 2021 and 2022, assaults resulted in 57,610 injuries. In 2022, there were 525 fatalities due to the assaults that were reported, according to Injuries Facts, National Safety. Workplace violence in dentistry can and does occur. In 2009, one person dead, four injured due to a shooting in a dental practice in Semi Valley. In 2019, a man entered Guy Dentistry in Colonial Heights, Tennessee, and shot and killed his wife who worked there. Another patient in the office with a carry permit held the gunman at gunpoint until law enforcement officials arrived. In 2022, a disgruntled patient shot and killed two dentists in Tyler, Texas. And most recently, a young 28-year-old dentist was shot and killed in his practice in El Cajón, California. So, with that information, we have a lot to consider when it comes to whether our workplace could be subject to a violent situation. And it may not be someone that enters your practice. I'm going to ask Olivia, first of all, to explain to us why dentists need to have a workplace violence plan.
SPEAKER_02Leslie, you know, it is required. And interestingly, when I've had dental offices reach out to me who were audited, the OSHA official is looking for that plan. So it is required to have a plan. And also, Leslie, whenever there's not a specific standard, that gets captured under the general duty clause, which is like a blanket clause, so to speak, that encompasses any hazard in the workplace. And it basically requires the employer to provide a place of employment which is free from recognized hazards that are causing or likely to cause death or serious physical harm to the employees. And so you mentioned these different incidents that have occurred in dental offices. We know it's been in healthcare, but it is specifically happening in dental offices also. So now we recognize it is a hazard. And by not having a plan in place, then that means that the employer is just turning a blind eye to it. And the employer can actually be cited for violation under the general duty clause if a recognized serious hazard exists and the employer didn't take any reasonable steps to prevent or abate the hazard. And so the following elements are required to prove a violation of the general duty clause, which would be OSHA's obligation, that the employer failed to keep the workplace free of a hazard to which the employees were exposed. There was a recognized hazard in the first place, and that the hazard was causing or likely to cause death or serious physical harm, and that there was a feasible and useful method to correct the hazard. So we definitely need to get on board and update our plans to make sure we're addressing workplace violence.
SPEAKER_03That's great, Olivia. And there's one other point that I think that we should tell our listeners is that when it comes to the general duty clause, employees have a responsibility too. It's not just the employer who sets the plans and conducts the training. Employees have to follow those safety plans as well. Mary, can you tell us what is a workplace emergency? And then tell us what the four types of workplace violence are.
SPEAKER_00Absolutely. And one of the additional incidents that happened in addition in February of this year, in addition to the dentist who was shot to death in California, there was or is a dentist in New Orleans who was actually treating a patient, and the patient pulled a knife on her and stabbed her multiple times, including in one of her eyes. So in both of those cases, the dentist who was killed in California, these were young people just a couple of years out of school, just starting their careers. And it's just sad to know that there are so many violent actions happening in a dental practice. Where in the past, we would, if you asked a team of dental um employees, what's a workplace emergency, they'd probably say a fire or a tornado, maybe a flood. And certainly those are on OSHA's list of emergencies, but hurricanes, of course, we have to have a plan if there is a hurricane forecast, a toxic gas release or a chemical spill. Many people don't realize that if you spilled a jar of formicreosol in your office, that is classified in most states as a toxic chemical release. And you need to have your facility evacuated and call the hazmat team to come take care of that. That would be a large quantity, not just a little drop or two. Um, chemical spills might be a mercury spill. That's a whole other category of remediation. Um, radiological accidents, explosions, a civil disturbance, and workplace violence are all listed as by OSHA as workplace emergencies. And so they OSHA has had an emphasis over the last few years about um workplace emergency planning. And we mentioned this in a previous podcast because OSHA has an e-tool that a practice can use to help create their emergency action plan for all of those types of emergencies that could happen. And now, because of these incidents that have happened recently, there's a heightened awareness of workplace violence in dentistry, but in a lot of employment settings because of things that have been happening. So there are four categories that the CDC and OSHA have kind of collaborated on to define in terms of what can happen. The first one is some kind of criminal intent. Um, that would be probably a good example of what happened to the dentist in in California, although it was allegedly a disgruntled former patient. But somebody who is an active shooter who just wants to kill a bunch of people could come in into uh a dental office and just start shooting people. Could be a patient, um, could be someone who's unhappy about something, the way they were treated, or they didn't like the the bill, or so that's just a sad thing to think that that's what we've sort of devolved in into in our um in our society right now, could be worker on worker, two employees who are at odds with each other. Um, I have personally witnessed a fight between two dental assistants in an office, a hair pulling, punching fight, literally in an office that had a lot of other issues as well, but that was just kind of a manifestation of that. And I will tell you it was not pretty. Um, or it could be some kind of a personal relationship, domestic violence that spills into the workplace. So the bottom line is we need to develop as dental teams a heightened level of knowledge of what to look for. What kind of signs might we see in a patient that might go ballistic on us? Um, or are there issues that we think might escalate between employees? Hopefully those get diffused. And if somebody has some kind of a domestic issue that they think could spill into the workplace, then they need to let someone know so that they can sort of have their back and be on the lookout for these people that may come in to the office seeking to harm that person.
SPEAKER_03Mary, that's all fantastic information. So we have criminal intent, we have maybe a patient who's disgruntled, we have worker on worker, so maybe two individuals that work with the practice can't work out their differences and it escalates. And then we also have personal relationships where it's someone, maybe uh ex-boyfriend or ex-husband or ex-wife, for that matter, comes into the workplace. You mentioned a compliance device podcast that where we had emergency action plans. That was podcast number 105. So I recommend that our listeners take a look at podcast number 105 after they look at all the wonderful resources we have and listen to that for the other parts of emergency action plans that you might need. Now I'm going to move over to our diva Linda in talking about how you would set up a site-specific workplace violence plan. And my understanding, the way I read the regulations, it's something where the team members need to be involved and get input. So it's very much like a meeting that you'd have to have, a staff meeting, as opposed to a document or a policy that someone just reads. Can you tell us about the five elements of setting up a workplace violence plan?
SPEAKER_01Sure, Leslie. It's interesting how workplace violence has risen to the top of importance in these days. And as Olivia mentioned, it's a recognized hazard. And also that poses a legal risk for our doctors and their practices. So having a workplace violence plan is of utmost importance, whether they include it in an existing plan, such as their injury and illness prevention plans, or maybe their existing emergency action plan. Doesn't matter where they have it, it just needs to be very thorough and very delineated, as Mary was mentioning to us. So Leslie, this workplace violence plan should have five components according to OSHA's guidance. The first is the management commitment and employee employee-employer participation. So management commitment would mean how do you illustrate that? What's your good faith effort? You know, for a management team, and I'll just say even just an individual practice with a dentist, you know, if the dentist says one thing and doesn't follow through with the safety tips and updates and recommendations, then there's no action behind that. There's no real good faith effort. So what's the good faith effort that you're making and how can you defensively document that and have that training throughout the staff? So management commitment and employee and employer participation, as you mentioned, that's looking at things together. What do they do the employees feel unsafe in some times? Maybe there's certain ones that are going home later than the others. And when it's darker in the evenings, you know, there's no good lights outside. They feel unsafe. So it could be anything simple along those lines, but looking for the details that make a difference. Next is a work site analysis. And I sort of crossed over to that one. I said employees will give information and share areas that they're not feeling safe, but also there's some e-tools, as Mary mentioned, that you an office can use to help evaluate their practice and look for unsafe areas. Are there locks that don't work? I'll share with you an example. This is a different type of OSHA violation, but not too long ago I was in an older practice, sort of in a strip mall kind of area, and the back the lock on the back door didn't work. So they actually had a bar going across the entire door that you had to take off before you could go exit the door. And that kept people from coming in. So that kept them safe from outsiders coming in. But when you would try to escape, that door was not OSHA compliant. So without a visualization, I may not have described that very well, Leslie, but essentially they were bolted in the with this big bar across the door that they had to remove. So that's part of a work site analysis. And then implement the health prevention, pardon me, the hazard prevention and control. So what are the hazards that you've identified and how do you plan to mitigate them? Can it be just as simple as having a handyman come and install some new locks or some new lights? Is it as simple as, okay, when staff leave in the evening, they leave together, nobody leaves alone? Just maybe you're in an area where you feel like you need to have a security officer at different times. I have been in offices before where they've had a security officer outside just because they they saw a high volume of patients and the type of nature of their practice warranted having that extra protection. Fourth is safety and health training. That's the training component that you mentioned earlier, Leslie. And having that documented is very important. And last but not least is the record keeping and program evaluation. You know, OSHA requires that the bloodborne pathogen standard be reviewed and updated every year and that be documented. So we should not just limit it to that one scenario. It should be all of your OSHA safety policies and procedures. And it doesn't have to be an all-day affair. It could be something simple as far as different team members reading to update and getting that participation again. But Leslie, as you all mentioned earlier, we have two podcasts on this topic. The first one was number 105. Is your office prepared for an emergency evacuation? But we also have episode number 148, tools for more effective safety meetings. So we have lots of information to help our listeners to implement this. This doesn't have to be an entirely different meeting on its own, or it certainly can be. Many times today's practice is hurried, they're shorthanded, a lot of patients on busy schedules. This can be easily incorporated into existing meetings. Just make sure you give it enough time and attention to get it started. Thanks, Leslie.
SPEAKER_03Linda, amazing information. So, in recap, we need to make sure that we have training. We have to have commitment from the top. So the management has to commit to a workplace violence plan and not minimize the possibilities of this occurring in their setting. Employees need to be trained to recognize these hazards. And that's where the input comes in because an employer may not know that someone doesn't feel safe walking to their car after hours when it's dark outside alone. So there's other situations that might be not connected directly connected to when you clock in, but when you clock out as well. And then as Mary had mentioned earlier, recognizing potentially hostile situations. I know that many times people who are working in a dental office may say, well, let me go get the manager for a patient is upset. And so the office manager or office administrator might come to the front desk and instead of uh having de-escalation tools, might end up being like just throwing gasoline on the fire and escalating it. So the training would include who to contact, how to report, what kind of de-escalation tools you have. And then also we want to make sure that we keep in mind that we might have to run, we might have to not be where that patient is. And that's of a document to talk about when it comes to retired fight run. And we have a poster that you can download that's from FBI that explains the exact uh sequence of things. They also mention, just like the blood-borne pathogen standard, it's also mentioned that we have engineering controls and then work practice controls. So engineering controls are physical changes that either remove the hazard from the workplace or create a barrier between the worker and the hazard. An example is door locks that we might have for our front door, but also how about that reception room door? Is that door locked, or could someone walk in and come around to the clinical area or come around to the front desk that's not authorized to be there? So if we have uh consideration on how our office is set up, panic buttons might be installed in some places. Um there might be better or additional lighting, uh, more accessible exits, like you mentioned with the bar across the door from the inside, or even uh doors that require a key, a deadbolt. And if you take the key out from the inside, someone has to look for the keys to open the deadbolt to get out. Um, and there's other methods and measures that should be site-specific based on the hazard identified in the workplace. Now, in some cases that are high crime areas, I have a client myself that has a security guard that's in the parking lot because they're in a high crime area. And the office is very nice, but and and it might seem intimidating to have, well, why do they need a security guard there? But it actually makes the patients feel better about getting out of their car, leaving their car, walking into the building, and not having anybody mess with their car while they're uh you know having dental treatment done. So surveillance cameras might be another type of engineering control. Then there's the administrative controls, and these are controls that affect the way staff perform jobs or tasks. Now, this might include hiring individuals who you've done a background check with, uh you've done a background check on them. It might also indicate that you need to have certain onboarding with your new employees so that they have an idea of what the workplace violence policy is and have an opportunity to speak with management on their perspective. You might limit workers from working alone. And if there is a situation where a patient seems like they're escalating their hostility, use the buddy system, especially when personal safety may be threatened. So while we're at the topic of workplace violence, I thought I would check back with our diva Olivia, our legal eagle, who uh shares what you could do if you had to fight and what you could use for a weapon.
SPEAKER_02Sure, Leslie. And I I wanted to first emphasize that the sequence is first you run. You want to run away from the danger. So if an assailant is coming toward you, such as an active shooter or someone with a knife, you want to run. And if it's not possible to run, then you would hide and take cover. And if that's not possible, the last resort is to fight back. And so in speaking with groups on what their plan would be to fight back, get some ideas from your team. And we did the very same discussion with my own law firm to find out what each individual person's plan is if an active shooter or violent person came on site. And my associate attorney mentioned that she would use the fire extinguisher. Whereas my front desk person said they would use bear spray, not pepper spray, but bear spray, because it shoots out like 35 feet. It's available on Amazon for about $35. So there's different things that you can put in place and use as tools. Even wasp spray could be used to fight back and give time so that if someone's calling 911, that law enforcement can show up. So there's different things like that. And if someone wanted to resort to fighting back, whether that involved the use of a handgun, that's going to be up to that person, up to the employer. And that's why we need to discuss it. So there's a plan in place. But definitely like the idea of using bear spray and fire extinguishers.
SPEAKER_03And thank you for correcting my sequence of orders. In fact, uh, one of our resources is going to be the FBI. Active shooter poster. I have been researching workplace violence for the last couple of uh weeks here, and it was easy for me to forget that. So, would it be uh appropriate to post one of these active shooter posters, maybe with your your other uh posters that you have in your dental office, maybe announcements or or your uh protocols or policies where employees can see this information and keep it top of mind. Do we have any other comments? So, Mary, you've got something you'd like to add.
SPEAKER_00I love your suggestions, Olivia. The bear spray, the wasp spray, whatever, the fire extinguisher, whatever we have on hand if we do have to try to defend ourselves. But looking at some very simple strategies for prevention, I have told all my clients for years keep your private entrance door to your practice locked. Don't leave it unlocked. And some people think it's so inconvenient. Oh, I have to get my keys out to come in. But somebody can easily sneak in a back door. Um, we had an incident in Michigan a number of years ago where that happened, where um a soon-to-be ex-husband snuck in the back door undetected, had his wife cornered in the break room and killed her before anybody could even respond. He had a hammer and beat her to death with a hammer. So keep those doors locked. If you take a lot of deliveries of products that you don't want coming through your front door, then you can always put something very simple like a ring doorbell camera at your back door so that you know who's there. And keeping, as you stated, I think, Leslie, keeping the doors locked. If you're the first one there in the morning and you're in the office by yourself, you're the last one there at night, keep the doors locked. Very simple strategies. Um, but really look at that private entrance. I know a practice, in fact, I used to work in the practice, and the private entrance was always unlocked for the convenience of everybody coming and going. And someone came in one day and stole everybody's purses and coats and things out of the back of the office. No one even knew because that door was unlocked. So that's my favorite strategy: lock the door.
SPEAKER_03You know, that brings to mind, Mary, something that happened at a dental practice. I was attending a HIPAA course and we were talking about security of the office and outdoor security. And a dentist had shared that she was um alone. She had seen a patient, she was practicing alone. It wasn't a habit that she had a patient that needed to be seen. And someone walked in, so she uh excused herself from the patient and went to the front desk. And uh the person asked uh you know, some kind of question about uh new patient would ask. And then um the patient uh, well, the doctor went back to her patient, but the person who came in the reception room made the door sound like it was closing, but he actually didn't close it. He just made it sound like it was closing. He hopped over the reception desk, stole her purse, her keys, her wallet, uh, found her car in the parking lot. And uh, you know the rest of the story when you when you have to uh go and find uh redo all your credit cards and make a police report. So uh that's very important, not only for workplace violence, but uh for security of our personal possessions. We we bring purses and keys and you know other high-tech devices, cell phones and whatnot. We don't want those stolen, and we don't want people in unauthorized areas. Linda, you wanted to chime in.
SPEAKER_01Leslie, I'd like to comment on one of the items that Mary mentioned related to patient-related issues. In the past year and a half, I've been in no fewer than three different medical offices and facilities where they have posters and or written behavioral contracts for patients to sign. So this is a new trend that I'm seeing. It's increasing. I mean, I've actually, as a new patient in a medical office, I signed a behavioral contract of how I would behave in that practice and not, you know, aggressive, violent. I don't remember all the wording now. Otherwise, I'd be dismissed. And when I went to give lab work recently, the scroll underneath the television had the same thing. Everybody's sitting there watching, not shows, of course, but there's different health information on those TVs. And it talks right there about patient management and patient behavior. So something we need to be thinking about in our dental practice is setting the tone up front with that management commitment and that communication, team participation, and make safety all the way around very important.
SPEAKER_03And I bet when you have staff involved, that people will bring to the attention of management things that management did not think of originally. So that is so important. California has a new law. It's SB 553. It requires nearly all California employers, including down practices, to create and implement a written workplace violence prevention plan and to train employees on that plan by July 1st of 2024. There's very short notice that we have on doing this. Now, uh, there's been some misunderstanding on uh who is required to have what what employers are required to provide this training. CalOSHA consultation in my Sacramento, that's my local office, confirmed that the regulation applies to all places of employment, even if they have less than 10 employees. And there's been a misconception in California that you needed 10 or more. What they say is the exception is where there are less than 10 employees working at the place at any given time, and that are not accessible to the public. If places are in compliance, of course, then they would have this in their written plans. But the keyword, the buzzword is and. So I just want to reiterate to our California podcast listeners that we are subject to this regulation, and there's no exemption unless uh an employee has no interface with the public whatsoever. And in a dental office, unless it's teledentistry, we interface with the public and their families and their people that bring them. And many times our offices are uh in places with uh public uh access. So this is a very important type of uh topic to discuss with your team. Don't wait until something happens either in your neighborhood close to home or in your practice. In wrapping up the program, we encourage you to tune in to our next podcast. And we bring clarity and simplicity to compliance by navigating regulatory compliance to keep you on course and keep you safe. We encourage you to submit your questions to support at thecompliancedevas.com. And when you do uh listen to our podcast, if you could scroll down and leave us a review, we'd love to know how we're doing in providing information to the dental community. Thanks so much, everyone. We enjoyed this podcast today. We hope you will too.