And another erudite and humble individual that we are blessed to have with us today. Dr. Michael Hodgson is Chief Medical Officer and Director of the Office of Occupational Medicine and Nursing at OSHA in Washington, D.C. Over the next 40 minutes, we'll go through typical OSHA citations that you probably need to know because everybody winds up with credibility in your hospital, because you can deal with the safety side and the C-suite, and they all care about that. We'll talk about the Health Care National Emphasis Program and the standard briefly, and then we'll spend a little time about violence prevention and what the different, you know, Joint Commission, OSHA, and various organizations think about. And finally, where the record-keeping thing is going, because next year, all of you will wind up getting pressure around recordable events. People should know that OSHA, most hospitals, most hospital CEOs care much more about the Joint Commission than about OSHA. And OSHA does acknowledge that, but doesn't really act that way. OSHA does see that there are problems in hospitals, and healthcare, NAICS Code 622, hospitals and 623, nursing homes, are among the high-risk industries in the U.S. So what does OSHA do when it goes into a facility? Well, it often looks for the easiest thing to cite, because our compliance officers, you know, they're not officially under productivity guidance, but they need to catch somebody's attention because there are very few systems that are as committed to the preventive principle as Yale New Haven and what Dr. Bruce just laid out. And in general, we struggle with that. So OSHA inspectors will try and cite what's easy, but they probably won't dig much. So it's worth knowing what OSHA goes after, and it's worth knowing both to prevent citations and because you can use that for increased credibility. So one of the easiest things is record-keeping. Are you actually keeping your logs up to date on the sharps injury log? Are you acting on that appropriately? In the last two years, record-keeping were the most common citations after respiratory protection. And respiratory protection is easy to cite, as many of you know, as you think about who does those exams. Are you doing fit testing appropriately? Are you tracking that appropriately? The record-keeping, though, is where much of the attention is going to be going over the next year because of the 300 log submission requirements. And then as you think about the rest, they're general safety issues. So knowing your safety folk and being able to think with them about what the risks are, pointing this out to them, and knowing where to find the injury, the citations on the OSHA website is a useful thing. Lots of people have, most of you have had to deal with the healthcare, you know, the infectious disease standard, the temporary standard, and now, and the healthcare emergency temporary standard that has been withdrawn except for the record-keeping provisions. So officially, all OSHA is doing in the current emphasis program in healthcare is looking at whether or not people are recording COVID cases, hospitalizations, and deaths on their log. But the guidance, the compliance directive, the CPL, and if you want to know what OSHA inspectors are supposed to be doing in any industry, you type in OSHA, CPL, and the industry, and it'll pull up OSHA's compliance directive, our public guidance, the inspectors on what they're supposed to be doing in your directive. So there's, there are several CPLs in healthcare, and it's worth knowing those, the hospitalization and death, but there's also a phrase in that emphasis program that says, if people are doing all of the things that were required under the old ETS, there are no other pertinent standards that OSHA will look at. So it's just worth knowing that. The healthcare infectious disease hearings went through Monday. The testimony is online, and it's worth looking at. For many people here, knowing what we do about N95s and protections, and having listened to Dr. Russi, you will remember that we think of COVID as an airborne transmitted disease, and occupational physicians have believed that since SARS-1. And I have a little disagreement with SARS-1, because the other New England Journal paper that says transmission is the Amoy Gardens outdoor modeling, documenting that the wind corridor in those different apartment buildings is as likely a transmission route. So two competing New England Journal papers where there's not enough data to say which one, but both have to have been airborne transmission. So the testimony last week on the infectious disease standard says very clearly, OSHA failed the country because OSHA stuck to the CDC guidance and didn't say what occupational health professionals, occupational physicians, and people who think about the transmission node have known for 15 years, namely that these things are in fact airborne transmission so it's worth looking at some of that testimony if you have arguments. It's all going to be available in the docket. And I think the, I didn't get my slides in to you in time to be put on here, but I think they're going to be posted somewhere on the. Oh yes, yes. The slides will be available to participants after the session, so all of the slides will be sent to you. So don't try to write everything down, please, or take pictures of every slide, no need, no need. And the URL where you can find all that docket, there's that OSHA coronavirus healthcare rulemaking. So let me go now to the bulk of what I think I'm supposed to be talking about, which is violence prevention. People forget that or don't believe that or unwilling to accept that healthcare is a violent, has a huge risk of violence in the U.S. After law enforcement, it is, you know, has the highest rates. We'll look at that in a minute. There's disagreement even among the federal agencies about a definition. NIOSH and OSHA use different definitions. Some questions around, you know, disruptive behavior, the way the Joint Commission defines it is included in the OSHA definition. NIOSH doesn't want to touch the psychosocial stuff. Violence rates have been going up. If you look at the Bureau of Labor Statistics data, the rates have, you know, increased by 25% over the last 10 years. And it's more than, in general, about five times what private industry is overall across all hospital and nursing home and outpatient settings. When you look at subgroups, you realize there are huge differences. And it's worth looking within your own hospital, whatever recordkeeping system you use. And lots of people have a single recordkeeping system, namely OSHA recordables. You know, when I was lead in the Veterans Health Administration, we built our own system so that we had far more stuff recorded than had to be recorded for OSHA. And you want to know even minor things. When you start looking at that, you realize, you know, hospitals, five times the rate. But psychiatric and substance abuse hospitals, 114 cases per 10,000 workers. In continuing care and retirement communities and the elderly, they whack at their nurses. And they actually cause lots of difficulties. Because anybody who's dealt with Alzheimer's patients knows they lose their inhibitions. And it's not just that you can be kind to them. They become psychotic in unpredictable ways. And so recognizing that the sections in your hospital that pose the greatest risk are probably the ED, wherever mental health patients are treated as an outpatient, the closed wards are huge risks. Overall, in over 40% of all injuries in healthcare are, overall, 40% of all injuries in healthcare are violence. And nationally, three-quarters of all incidents that are violent occur in healthcare. So when you think about the issue that three-quarters of the assaults in the American workforce happen in our industry, we recognize there are some reasons to have very structured approaches to intervening. For the last 25 years, NIOSH and OSHA have come up with a set of documents around developing programs. I'm going to go through the OSHA guidance document, because it has structured elements. But it's worth thinking carefully about each one of these bullets, and looking at your own hospital and thinking through how much of this you have done. In January, we published a deep dive with 12 criteria statements about program evaluation. And right now, we're working on a crosswalk between the Joint Commission, this document, and our 12 criteria statements. The question is more, do you internally do what the Joint Commission does with, you know, a tracer approach? If you have an incident, do you follow back where what went wrong? So all OSHA standards are really constructed in the same way. Do you have management commitment and employee participation? You know, what proportion of hospitals have labor unions and union representation? There are countries where unions have a mandatory seat on the board of directors. We don't have that here. So in fact, National Nurses United and other kind of labor groups aren't often well represented in hospital management. Has somebody done a worksite analysis, and is there ongoing hazard prevention and control? What's the training, and what are the record keeping and program evaluation elements? Do you have a structured way of looking at incidents and making sure after action that you can solve those problems? So management commitment and worker participation, what does that mean? Has anybody allocated appropriate resources? Is there somebody responsible for managing that program? OSHA doesn't ask whether you have a program, but it'll ask what's your, who is doing, do you have a written document that says here is what your hospital does? Management commitment means there's a system of accountability. Are there annual reports or reports of investigations? Are there policies on reporting and the like? OSHA's language is, have you looked at the physical locations and procedures? So do your doors open or close? Do they have lock? Do the nurses have protected places they can let down their guard? Do you have a structured way of looking at records, and do you conduct surveys? So do you actually look at your log of incidents to look at rates of events in different places, like if you have a closed mental health ward, what goes on there? When you do hazard analysis or when you do environmental, environment of care rounds, who actually goes along? Is it just clinicians, or is it the safety side that understands some of the facility guidelines, institute guidance on how do you create, how do you build a hospital that meets criteria for doors opening in the right direction, locking doors, self-closing doors and the like? And as you go through that, this is not a one-time thing. So you have to make sure that the emergency call buttons actually work. You have to make sure that your post-incident procedures don't decay. So even if you have, like in the VA, what's called a disruptive behavior committee, where people look at every incident that are supposed to look at every incident that causes trouble, that habit may decay. We recently looked at a VA fatality that occurred because the VA wasn't following its own procedure. So where the disruptive behavior committee that is supposed to look at each one of these incidents is supposed to be chaired by a clinician, they had started, they had had the police chief chair that committee. And when somebody complained, the chief of mental health complained that a worker and employee was stalking him out in the community, the chief said, it's not on VA grounds. That's not our problem. And that employee patient who had meanwhile been fired wound up going past the, it was a joint military base and VA hospital. The guys at the front door at the gate knew him. They let him in with a weapon. That weapon was loaded and he shot and killed the head of mental health. So procedures decay unless there is someone actively looking at those procedures. Things can go very wrong. So know your organization's policies and think carefully whether people are actually following those. Training. How does that training happen? Is it captured in, what are the training elements? So we include de-escalation as a critical element. So many hospitals do have de-escalation training. Unless you practice that, you won't know how to do that. And so the best, we recently looked at 12 different commercial programs, all of them had de-escalation training, but not all of them practiced it or helped facilities understand that they had to locally, you know, build in practicing the de-escalation so that people knew how to do that when time came. And then the record keeping, where do people report that? And does a system exist to do that? OSHA logs are one thing, but what shows up in the internal records, the OSHA records are in fact publicly accessible. So in general, mental health patient diagnoses, the quality of care that may have been inadequate and led a group to fail to recognize escalating behavior, those won't show up in the OSHA log data. And unless the institution has a way of looking at medical records, understanding prior history of violence, tracks that in meeting minutes and the like, your facility is at risk of recurrence. And so after, you know, on a regular basis, whether that's every six months or every year that there is somebody who is looking at the program and its effectiveness is a critical element of program management. So there are lots of different resources that you can use. There's an OSHA guidance document to structure data for people to structure these programs. Large systems often have a policy for the whole system. So if you work in the Hospital Corporation of America or any one of the healthcare systems, you're gonna have a policy that goes across all of those institutions. People who have followed the rejuvenation of the patient safety, employee safety integration. Actually, let me ask, how many of you know about this initiative between the Joint Commission and the National Patient Safety Foundation kind of rejuvenating patient safety? No. So over the last two years, about four years ago, the CDC called out a national activity to rejuvenate patient safety under the auspices of NPSF-IHI. So a series of organizations came together and thought about what are the things that are currently missing in the way we are doing this nationally. And there were four different, actually, trying to remember whether I didn't. Maybe I did. I thought I had a slide here, but clearly there is no slide on this. So integrating employee safety into patient safety is one of the four big activities, and at the top of that list is, in fact, violence prevention. So the NPSF-IHI website has a series of programs that program elements and documents that help facilities get at that. Safe patient handling is the second thing on the list. OSHA has its websites. Each of the area offices has compliance officers, and nationally, we have a regional workplace violence coordinator. So facilities, if they choose, and most facilities, we realize, won't call OSHA for help, but there are regional coordinators whose role is to help our compliance officers, but also to help anybody who calls up set up programs. So OSHA doesn't have a workplace violence standard, although there is a, if you search, you'll find the Notice of Proposed Rulemaking that had come out, and we still have that on the books. The next step in promulgating that standard is what's called SBREFA, the Small Business Industry Review, and that's likely to happen in the fall. Nothing for anyone in healthcare to do until then. OSHA is still enforcing under the General Duty Clause, and there are some traditional things that we look at. Many of you will have encountered the General Duty Clause elements in some place. Right now, ergonomics and violence are the big 501 citations that we push, and as OSHA goes into healthcare, it's actually pretty easy to document that most facilities are not meeting the General Duty Clause or meeting the criteria for a General Duty Clause violation. Does a hazard exist? The data nationally are overwhelming that they are. The hazard is recognized by the employer and the industry. It is likely to cause death and serious physical harm. OSHA defines serious physical harm as losing work time, and the question of feasible abatement is really the critical issue around any individual incident that we cite. So as you think about the incidents that you have, that you encounter in your facilities, the question is, what could have been done to prevent those? So there are lots of interesting trials now, even with wearables. So there's a clinical trial out right now with a personal alarm where people just have to hit their chest, and the wearable vest actually triggers the emergency call button. So there are those kinds of things going along, and how do you deal with emergency calls and response to those is one of the sad, after the fact, issues that are commonly a problem, but it's preventing getting to that that these programs are really about. What's happened in these inspections? Well, we did our first workplace violence inspection in 2004. This graphic documents what's happened in terms of overall inspections. The summary is the sum of those three lines. The bottomless line is the number of 5A1 citations. The line in red is the facilities where we send out hazard alert letters, and that line in between is where we didn't think things needed to be done, where we thought facilities had a good enough program that we could do an inspection and say, eh, this is not a problem. And you can think about political changes and administrations, and obviously OSHA has a political appointee at the top who does some, you know, influences enforcement policy in certain ways, but it is pretty clear that hospitals are getting better. And as we looked at, in a deep dive, the facilities that had received general duty clause citations and that had received hazard alert letters, we have good evidence that the HALs, the HAL facilities had far better programs than the ones with 5A1 citations. But, so this is a solvable problem. There are still some things that can happen, but if you have a fully functioning program, your rates are gonna be way lower. There's a workplace violence standard under development. The NPR came out of this request for information on the scope of the problem controls and core elements. We're planning the small business review process for the fall. And for facilities that care about this, the ones that may have a stake in those hearings, you know, people may wanna start preparing their responses to what they want. There is gonna be a fair amount of tension on whether OSHA should promulgate a standard in the same way that there is a lot of tension on whether OSHA should promulgate an infectious disease standard. To remind people of the infectious disease standard, it has been under development since 2010. Here we are 12 years later. It didn't happen for many years, but because OSHA, I can say this as a private citizen, OSHA really did fail healthcare by not going out ahead of CDC. It is not unlikely that there will be a healthcare infectious disease standard because the economic consequences of COVID, the failure to do things appropriately. So as you think about whether you want a violence prevention standard or whether you want to shape that, it's worth recognizing what OSHA may focus on in the small business review panel. And so the things that, oh, I'm way ahead of where I thought. So the things that OSHA would suggest you think about commenting on are not just generally prevention programs, but how should, if OSHA promulgates a standard, how should it say you should do hazard assessments or what are the control programs? So for example, in the clinical world, increasingly hospitals are following the VA model of having clinical input into after action reviews on violent incidents. There was a time where this was purely a safety and law enforcement approach. The VA piloted, developed a model back in the 80s on clinical reviews of patients. It's actually a JAMA paper from 1989 documenting that if you systematically look at your violent incidents in outpatient settings with clinicians thinking through what happens, you can put appropriate warnings in the patient record that will prevent those incidents. And that turned into a big VA program. Lots of private sector hospitals now use that. I don't think anybody has published those as yet, but when I call facilities around the country, clearly many of them have those in place. And so if people wanna shape an OSHA standard, it is important to put that, to put, to offer input into the standards we promulgate. So the, I think the last thing I was gonna talk about was that record keeping is, you know, how you track things helps you evaluate programs and has all kinds of consequences for OSHA. In the past, OSHA, you know, looked at the Bureau of Labor Statistics data and would design its high risk kind of programmed inspection activities around industries with NAICS codes that have high injury rates. And in fact, almost 10 years ago, the so-called National Emphasis Program on Recordkeeping documented that facilities in high risk NAICS codes, so hospitals, nursing homes, meat packing, that had low rates of injuries reported on their 300 log had between five and seven times as many what we call record keeping errors. They failed to report things that they should have reported. OSHA didn't go so far as to say, that's clearly active misrepresentation of the world at large, but OSHA has believed that for quite some time. Some of you know, the B Corporation model of trying to drive performance by publicly putting up data. How much do you spend on environmental management? How does that drive the public's perception of an employer? OSHA has for a while tried to develop something like that. And so under the, before 2016, the record keeping rule revision that was posted suggested that all employers should submit their 300 logs to OSHA. We would make them available publicly, and then everybody could see how much effort was being expended by organizations to reduce their worker injury rates, meaning public driving of employer behaviors. That didn't go anywhere over the last four years. Well, you know, from five to a year ago, it is back up. It has passed muster in a slightly different way. And it looks like next year, every institution that belongs to a NAICS code above the national average will wind up submitting their 300 log to OSHA. There's a huge consequence for that. So those of you who deal with OSHA logs know, you can figure out what kinds of injuries there are. Are they assaults? Are they patient handling injuries? Those records will be available for the 5,000 hospitals in the US. We will be able to benchmark our own hospital against other hospitals. People will be able to look at, for example, the nursing quality indicators that are mandated from CMS, that the American Hospital Association captures the nursing magnet data and look at those nationally for benchmarking data. So the rule, you know, it's the first, this year, lots of people had to report, but not all of the data. So if you remember, there's a 300 log, just the summary number. There's a 300A and a 301. So those records actually have other information on them. Namely, what are the details of the incident that happened? Requires some coding to actually use, but there are really interesting research opportunities. And so the proposal is that establishments with more than 20 employees will have to submit their 300A data. Establishments with 100 or more employees in the high hazard industries will have to submit, you know, all of their stuff. But employees with, establishments that are not in these designated high hazard industries will no longer have to submit any of those data. So it doesn't help healthcare because healthcare as a NAICS code will always be in those high hazard things. But lots of other employment segments have stopped, you know, resistance to this rule. So you should know that people will be looking at you and probably exerting more pressure, at least in some facilities around what is an OSHA recordable event. We could talk at length about OSHA recordability, but that's not part of this talk. The reason the record keeping rule has changed is to change public access and to make sure that that information is available and lets people choose and exert pressure. And I think that's the, right. So there's a public place to look at and to make comments, but that rule is on its way. Actually, I did put in some, you know, rates just for, so that you could look at hospitals, nursing homes, and some, you know, to look at the total case rate in blue, the days away and restricted time rate for people who care about those numbers. And I did throw in a organizational chart for OSHA in case people are confused by the agency because it is sometimes useful to know where you can go for, to complain. Dr. Rusci and I have had discussions about this because it's important to know that you can challenge OSHA citations when you disagree with the underlying tenor. Sometimes people think they should accept an OSHA citation because they think their local OSHA office will carry a grudge. There are ways to deal with that, even within the agency. And just let it be said that when there are citations that happen that shouldn't happen, there are ways to bring that up to the national office. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you.

OSHA citations

workplace safety

healthcare settings

record-keeping

high-risk industries

workplace violence

violence prevention