Instructions for the Review

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12 | Briefings on Hospital Safety July 2018

These workers, says OSHA, must be trained by a qualified person to correctly identify and minimize fall hazards; use personal fall protection systems and rope descent systems; and maintain, inspect, and store equipment or systems used for fall protection.

When there is a change in workplace operations or equipment, “or the employer believes that a worker would benefit from additional training based on a lack of knowledge or skill, then the worker must be retrained,” states OSHA materials. The training must be provided in a language and vocabulary that workers understand.

Remember to include falls safety when hiring a con- tractor to do work at your facility. Under OSHA’s multi-employer citation policy, it is possible for your

hospital as well as the contractor or subcontractor to be cited for an unsafe workplace or incident in which someone is injured or killed.

When dealing with a contractor, OSHA will expect a hospital to create a site-specific safety program, supervise and enforce the safety protocols for that project, and maintain authority to correct safety hazards, Salmasi says. Have regular safety meetings with contractors and subcontractors, document those meetings, and do regular inspections on-site, he recommends. H

EDITOR’S NOTE:

A version of this story first appeared in Environment of Care Leader,

a DecisionHealth newsletter.

HEALTHCARE SECURITY ALERT

Active shooters

Five key steps for creating, implementing an active shooter plan at your healthcare facility The threat of an active shooter roaming the hallways is one of the biggest worries among safety professionals and C-suite executives in the health- care industry.

Preparedness for active shooter situations is also on the minds of accrediting organizations and agencies such as CMS, The Joint Commission, NFPA, and OSHA, who have all recently called for better protection of healthcare workers from workplace violence or are currently considering new standards.

Steve Wilder, BA, CHSP, STS, has spent more than three decades in healthcare safety, security, and risk management, including stints as a hospital

risk manager and corporate director of safety and security for a health system. He has consulted with hundreds of clients, including hospitals, clinics, and physician practices, and has trained thousands of workers in workplace safety and security.

In addition to his regular contributions to health- care magazines, Wilder co-authored the book The Essentials of Aggression Management in Healthcare: From Talkdown to Takedown.

During a December 2017 webinar organized by HCPro, Wilder explained how to comply with the revised CMS rule for emergency preparedness and prepare your staff for any situation. He also helped attendees understand the key parts of an active

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shooter plan, went over how staff can improve deci- sion-making skills, and provided tips on controlling staff anxiety and stress during emergency situations.

In this 90-minute webinar—which can be viewed on demand through HCMarketplace.com—he shared his five key components for an active shooter plan. The following is a summary of that portion of Wilder’s presentation.

Step 1: Conduct a vulnerability assessment

Wilder believes the first key component of an active shooter plan is determining threats. Who might pose internal or external threats to your building or campus? How can you assess vulnerabilities that “are the chinks in the armor that allow an opportu- nity for a bad guy to strike”? Then you should consider the potential outcomes if an active shooter were to barge into your healthcare facility.

As a consultant, Wilder routinely does vulnerabil- ity assessments for healthcare organizations.

“We come in from the outside and see the things you see every day to the point where you stop seeing them,” he said. “I tell my clients, ‘We’re good guys that get paid to look like bad guys.’ ”

Wilder said that for an active shooter event to occur, three critical factors must be present.

“First of all, there has to be a bad guy. The bad guy is always going to be a part of our society. There’s nothing we can do to get rid of him. We can put one in jail and there will be 10 more stepping up to take his place,” said Wilder. “Secondly, the bad guy has to have a motive. I can’t do anything about the motive. That comes from inside his heart or inside his head.”

He continued: “And thirdly, he has to have an opportunity. … The only thing we can do is take away his opportunity to strike at our place, whether it’s a burglar or an active shooter or an

arsonist, a predator, whatever the case may be. The only thing we can do is take away his opportunity, and that’s what the security vulnerability assess- ment is designed to do.”

After identifying all the opportunities “for the bad guys to strike,” steps can then be taken to put programs in place “to minimize the vulnerabili- ties,” which, said Wilder, is “a great step.”

Step 2: Develop an emergency response plan

Wilder said an active shooter emergency response plan must keep in mind everyone who could come through your doors—including but not limited to patients, employees, residents, visitors, and ven- dors. “We’ve got to incorporate all those people in, because when we’ve got an active shooter in the building, we become responsible for all those people,” he said.

Wilder notes that writing an active shooter emer- gency response plan “is much more challenging in our buildings than it is in any other industry because a lot of our doors” can’t have locks.

And, he said, that plan “has to be realistic to the threat,” whether the shooter is looking for a specific person such as an ex-spouse, or whether the situa- tion is like “in San Bernardino a couple of years ago where the individual just wanted to spray bullets and he doesn’t care how many people he takes out.”

Regardless of a shooter’s motive, the plan should be written “with a survival mindset.”

“This is the one emergency code that is not going to involve a response team,” said Wilder. “When you have an active shooter, you’re not going to have a code team responding. People need to be run- ning the other way. If you’re involved in this scenario, that puts you in a position of having to rely on yourself for survival—ergo relying on your training for survival.”

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14 | Briefings on Hospital Safety July 2018

Wilder added, “We can be sitting ducks if we don’t have a plan.”

Whoever is writing your active shooter emergency response plan should be thinking of the answers to critical questions such as “Where are the exits?” and “Where are my hiding places?” as well as “Where are my weapons of opportunity to protect myself if I have to fight back?”

Wilder teaches a model called the “Four Outs,” which he called “ ‘Run, Hide, Fight’ on steroids,” and he discussed it in detail during the webinar. But perhaps the biggest difference between “Four Outs” and the “Run, Hide, Fight” model, which was developed by the Department of Homeland Secu- rity, is that the former considers options for setting up barricades in rooms with doors that don’t lock.

Step 3: Develop an active shooter training program

Once the written plan is completed, then you can develop your training program, said Wilder. Plan and program must be consistent, he stressed, because “catastrophic outcomes will result” if your written plan tells your employees to do one thing and the training program says something different.

He cautioned against buying a prewritten active shooter emergency response plan and training program online because they will not be tailored for your individual facility.

“Every one of you has different points of access. Every one of you has different hours that your perimeter doors are locked and unlocked. Every one of you has different visitor standards. Every one of you is different,” he said. “Why would you want to try to buy a generic plan that’s written one size fits all? It doesn’t work. You have to write your plan specific to your facility.”

HEALTHCARE SECURITY ALERT

Wilder recommends a four-step approach to training, starting with awareness, then preparedness “where we actually train on the content of our plan,” then exercises and drills. Last but not least, the fourth step is evaluating your plans and looking for ways to improve them.

“At the end of every exercise, we need to look in the mirror and say, ‘How did we do?’ ” said Wilder. “We’ve got to improve. This is a continuous quality improvement process.”

He added that training must be “all-inclusive”—yes, administrators and C-suite executives, too. And that’s not just because surveyors will hit you with a major citation if they discover executives skipped the training.

“Number one, just because you’re in the C-suite, you’re not immune to training,” he said. “Number two, as part of the chief executive branch, people are looking to you for leadership, and if you are not trained in the same program that your people are trained in, you’re going to be telling them to do one thing when your plan says something else —in the worst possible situation.”

Step 4: Train staff how to respond to an active shooter

After finishing an active shooter training plan that fits seamlessly with the emergency response plan, it’s time to actually start using it to train your employ- ees. Wilder said that all new employees should go through a facilitywide program as well as depart- ment-specific training.

Wilder believes employees should be trained to pick the best course of action from a range of options, so they can make the safest decision as quickly as possible. “And we want to make sure that they know how to apply those choices and when to make [each] choice,” he said.

He said that in a real-life active shooter situation, the first responses for everyone, including a trained

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that to prepare me so that in the event of an emergency

situation—when my adrenaline is skyrocketing, and

my pulse is racing and I’m hyperventilating probably,

I’m not thinking clearly and my mind isn’t working

properly—they want those responses to become

second nature.”

Step 5: Plan for the response after an emergency

In the aftermath of an active shooter event, you

must quickly initiate a facility crisis management

plan to return to a normal—and safer—state of

affairs as quickly as possible. Among the many

needs at that time may be a liaison to the media,

additional security, and crisis counseling.

The hours and days after this kind of emergency

will be chaotic, so plan ahead, said Wilder.

“At 1 o’clock in the morning when the shooting has

taken place is not the time for me, with shaking

hands and total anxiety, to be flipping through the

yellow pages looking for a crisis counselor or

additional security or whatever I need,” said

Wilder. “I need to do my planning in advance.”

safety and security professional like himself, would be “startle and fear.”

“And that’s OK,” he said. “Guys, this is scary. It’s OK to be scared, even if you’re well-trained.”

But what happens next, Wilder said, usually depends on an individual’s level of training.

“All that training is going to come back to the forefront of your head, and your response is going to be exactly what you were trained to do,” he said. “It’s amazing. I’ve seen it over and over and over. Your training kicks in. You might have forgotten everything about that training program, but your brain—that big hard drive in your head—all of the sudden brings it back to active memory.”

And if staff haven’t been trained? “They’re going to have a meltdown on you. They’re going to be useless. They’re going to be a liability to you and they’re going to get you hurt or killed.”

That’s why he scoffed at the thought of “people being scared to do these exercises.”

Wilder compared it to monotonous pre-flight instruc- tions from flight attendants, saying, “They’re doing

Security

Use new NFPA 3000 to improve community planning for mass casualty response Use a new NFPA standard to review your over- all preparedness for responding to mass casualty events and improve your coordination with other healthcare providers, first responders, and commu- nity emergency organizations.

Spurred by coordination problems identified after several recent mass shootings, NFPA 3000, a Stan- dard for an Active Shooter/Hostile Event Response

(ASHER), is designed to help communities prepare for multiple casualties. It was released May 1.

There is no current mandate for hospitals to embrace the standards set out in NFPA 3000, which was fast-tracked as a provisional standard in the aftermath of the mass shooting at an Orlando, Fla., nightclub in June 2016 (ECL 5/7/18). However, both CMS and The Joint Commission have noted

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