1. VIOLENCE PREVENTION Michael Hodgson, MD, MPH Director, Occupational Health Program and Dan McDonald, PhD EES/PMDB Laurent Lehmann, MD – Mental Health SHG David Drummond, MD – VISN 20 Mental Health Field Advisory Group

2. OUTLINE Data Problem Program Plans Conclusion

3. Figure 1: Assault by occupation and perpetrator of most recent incident

4. Figure 2: Verbal abuse by occupation and perpetrator by most recent incident

5. Figure 3: verbal abuse and assault by service

6. UNDERLYING RISK FACTORS Multiple diagnoses PTSD –Major mental illness –Substance abuse Geriatrics Personality style / Poor impulse control Prior assaulter Institutional Depersonalization Disrespect Interpersonal Family Work Economic PREDISPOSING PRECIPITATING

7. PREVENTION AND MANAGEMENT OF DISRUPTIVE BEHAVIOR Established late 1970s Evolved from 2 hour to 16 hour program Content –Overview –Personal Safety Skills –De-escalation –Therapeutic Containment Major review on content and strategy under way

8. STRATEGY Top management commitment –Quality Forum/Leadership Board –Reports Infrastructure development –Education program updating –Performance measures for systems improvement –Data / evaluation

9. SEQUENCE Year 1Quality Forum for senior management commitment Year 2National Stand-down (awareness) Local policy at each facility Year 3Trainer network Training plan Year 4Flagging (Soft ware, Local multidisciplinary committee, Clinical leadership) Threat assessment training Training (51% of high risk staff by Q3) Year 5DBC roll-up Threat assessment training

10. NEXT STEPS VAMP: “case-control” approach to assaults to identify victim, perpetrator, and environmental influences Training competencies and injuries: Instrumented training mannequin development Co-worker assault and abuse: Ethnography of civility and respect 2006: Quantitative re-assessment

11. CONCLUSION Violence in healthcare reflects underlying societal and individual problems VHA review policies, data, and procedures and developed a strategy in 2001 Patients are twice as likely as coworkers to be perpetrators Moving forward has required rethinking evidence, recognizing absence of empiric data on effectiveness, and fundamental weaknesses in threat assessment VHA is committed to quantitative evaluation of intervention effectiveness and outcomes