Canadian Health Accreditation Report. Preventing Violence and Promoting Workplace Safety in Canadian Health Organizations

Transcription

1 Canadian Health Accreditation Report

2 Accreditation Canada wishes to thank the authors: Qendresa Hasanaj, Health Services Research Specialist Jonathan Mitchell, Manager, Policy and Research Viktoria Roman, Health Services Research Specialist 2015 Accreditation Canada How to cite this document: Accreditation Canada. (2015). Preventing Violence and Promoting Workplace. Ottawa, ON: Accreditation Canada. Cette information est aussi disponible en français sous le titre Rapport canadien sur l agrément des services de santé : Prévention de la violence et promotion de la sécurité au travail dans les organismes de santé canadiens Cyrville Road, Ottawa, Ontario K1J 7S accreditation.ca

3 Contents Preventing violence and promoting workplace safety in Canadian health organizations...2 Executive summary....3 Workplace violence in Canadian health organizations...4 Workplace safety and quality of worklife in the Accreditation Canada Qmentum program...6 Workplace safety in the Leadership Standards...7 The Workplace Violence Prevention ROP....9 The Worklife Pulse Tool...12 Supporting organizations with program improvements and leading resources References...18

4 Preventing violence and promoting workplace safety in Canadian health organizations Workplace violence is a sobering reality in health care organizations. While workplace violence is most commonly associated with physical violence, it is not limited to physical aggression and includes acts of incivility, verbal bullying, spreading rumours, threatening words or actions, as well as sexual harassment. Most workplace violence incidents, such as verbal and emotional abuse, go unreported. Health leaders across the country are responsible for meeting applicable provincial and federal legislative requirements regarding occupational health and safety and violence prevention. The Accreditation Canada Qmentum program assesses organizational workplace safety and violence prevention against national standards of excellence to help health care organizations meet these requirements. The program also includes the Worklife Pulse Tool (WPT) to measure quality of worklife. This year s Canadian Health Accreditation Report provides information on key workplace safety and violence prevention findings. The observations of peer surveyors at the on-site surveys and the responses from staff to questions in the Worklife Pulse Tool provide valuable information that may contribute to positive changes for responding to workplace violence within the health care system. Safety is a right of every patient receiving care and every health care worker providing care. Accreditation Canada remains committed to supporting workplace violence prevention in health care organizations across Canada. Wendy Nicklin President and Chief Executive Officer 2

5 Executive summary Workplace violence is a widespread problem across health care organizations in Canada and internationally (Gillespie et al., 2015; Adams, 2012; Di Martino, 2003). One third of all workplace violence incidents in Canada involve a health care worker or a social assistance worker (Léséleuc, 2007). A safe workplace, free from any form of violence, is the right of every health care worker and critical to providing patients and their families with quality care. Workplace violence in the Canadian health system has a substantial impact on the affected health care workers or patients and on the wider health care system as a whole. Preventing workplace violence is a significant challenge for the Canadian health system and requires commitment from all health care leaders as well as continuous monitoring of trends in organizations. This national report presents aggregate data from health care organizations participating in the Accreditation Canada Qmentum program to demonstrate compliance with organizational efforts on workplace safety and violence prevention, as well as results from the Worklife Pulse Tool. The information collected offers a unique perspective on health care in Canada. Highlights include: While leaders of health care organizations promote a safe and healthy work environment and support a positive quality of worklife, there are opportunities for identifying and monitoring processes and outcome measures related to worklife and the work environment, monitoring staff and service providers fatigue and stress levels, and monitoring the quality of worklife. Opportunities exist for implementing a documented and coordinated approach to preventing workplace violence. These include conducting risk assessments to ascertain the risk of workplace violence, using quarterly incident reports to improve safety, and making improvements to a workplace violence prevention policy. Worklife results show that 84% of staff agreed that the people they work with treat them with respect. However, opportunities exist for senior managers to commit to providing a safe and healthy workplace and taking effective action to prevent abuse in the workplace. Results also show lower positive responses from staff providing direct care to clients and support staff (administrative, clinical and facility). 3

6 Workplace violence in Canadian health organizations A nurse was violently attacked by a psychiatric patient who wandered off to another unit while waiting to be admitted. A crisis worker, a doctor, an emergency room nurse, and a patient s mother were all seriously injured in a violent attack by a patient. [Adapted from Ontario Nurses Association (ONA, 2014) based on actual events that occurred] Workplace violence is a widespread problem across health organizations in Canada and internationally (Gillespie et al., 2015; Adams, 2012; Di Martino, 2003). One third of all workplace violence incidents in Canada involve a health care worker or a social assistance worker (Léséluc, 2007). For example: 54% of Ontario Nurses Association (ONA) members report having experienced physical violence or abuse in the workplace and 85% had experienced verbal abuse (ONA, 2012). Nurses are more likely to be attacked at work than prison guards or police officers (ONA, 2014). For example, A hospital patient, who was taken home by police after being discharged, came back to the ER to argue with the Registered Nurse and punched her twice in the stomach. (ONA, 2014) Workplace violence has important implications for health care workers, patients, and the health system (Kirwan et al., 2013; Bujna et al., 2015; Lundstrom et al., 2002): At the direct care provider level, workplace violence is associated with increased staff job dissatisfaction and lower levels of employee well-being. At the organizational level, workplace violence has negative impacts on employee satisfaction, commitment, turnover and the quality of care provided to patients. At the health system level, workplace violence contributes to negative patient outcomes as well as increased costs through absenteeism and disability claims. 4

7 Accreditation Canada has adopted the modified International Labour Organization definition of workplace violence: Incidents in which a person is threatened, abused or assaulted in circumstances related to their work, including all forms of harassment, bullying, intimidation, physical threats, or assaults, robbery or other intrusive behaviours. These behaviours could originate from customers or co-workers, at any level of the organization. This national report presents aggregate data on workplace safety and violence prevention from health care organizations participating in the Accreditation Canada Qmentum program, as well as results from the Worklife Pulse Tool. The information collected offers a unique perspective on health care in Canada. 5

8 Workplace safety and quality of worklife in the Accreditation Canada Qmentum program In 2008, Accreditation Canada partnered with the Health Force Ontario Health Work Environments Initiative to review and examine how well the Qmentum accreditation program addressed workplace violence prevention. The Accreditation Canada standards have always reflected the importance of quality of worklife (e.g., staff participation in decision-making, professional development support) as part of the worklife quality dimension of Qmentum. Following the 2008 review, the focus in this area was strengthened and the Workplace Violence Prevention Required Organizational Practice (ROP) 1 was added to the Effective Organization Standards for assessment at on-site surveys starting in In addition, for on-site surveys starting in September 2012, the revised Leadership Standards 2 (previously the Effective Organization Standards) were strengthened with the enhancement of a standard that promotes a healthy and safe work environment and supports a positive quality of worklife. Over 1,100 client organizations nationally and internationally (6,000 health care delivery sites across the care continuum) participate in Accreditation Canada programs. Client organizations differ greatly in size, scope, and context depending on their province or territory, their health care sector, and whether they are public or private. A client organization may be an entire provincial health system with many sites providing a wide range of services, or a single-site independent organization providing a narrower scope of services. 1 Required Organizational Practices (ROPs) are evidence-informed practices that mitigate risk and contribute to improving the quality and safety of health services. 2 The Workplace Violence Prevention ROP can also be found in the Independent Medical and Surgical Facilities Standards, Leadership for Aboriginal Health Services Standards, Leadership Standards for Small Community-Based Organizations, and the Medical Imaging Centres Standards. 6

9 Workplace safety in the Leadership Standards All client organizations use the Leadership Standards, which address leadership functions across all levels rather than individual position-specific capabilities. These standards clarify the requirements for effective management support, decision-making structures, and the infrastructure needed to drive excellence and quality improvement in health service delivery. From 2012 to 2014, the Leadership Standards 3 were assessed in 383 organizations, including 102 health authorities or systems, 113 long-term care organizations, and 82 acute care organizations among others. Within the Leadership Standards, the following standard is specific to workplace safety and quality of worklife: The organization s leaders promote a healthy and safe work environment and support a positive quality of worklife. This standard addresses the need for leadership to: Develop healthy workplace strategies to help staff and service providers manage their health Develop a confidential process for staff, service providers, and volunteers to bring forward complaints, concerns, and grievances Provide support to promote a safe and healthy work environment Organizations achieved high compliance with this standard. Table 1 lists the top three criteria with the highest compliance. Table 1: Leadership Standards Strengths, Criterion The organization s leaders are involved in quality of worklife and healthy and safe work environment improvement initiatives. The organization s leader s support continuing professional development and learning throughout the organization. The organization s leaders provide support for quality of worklife and healthy and safe work environment improvement activities. 3 The Accreditation Canada Leadership Standards for Small Community-Based Organizations, the Leadership for Assisted Reproductive Technology Standards and the Leadership for Aboriginal Health Services Standards are different and results are not included in this report. 7

10 While organizations achieved high compliance with this standard, results show that certain elements or criteria were not in place in more than 30 organizations (approximately 10%) from 2012 to 2014 (see Table 2). Table 2: Leadership Standards Opportunities for improvement, Criterion The organization s leaders identify and monitor process and outcome measures related to worklife and the work environment. The organization s leaders monitor staff and service providers fatigue and stress levels and work to reduce safety risks associated with fatigue and stress [by monitoring extended hours and experience surveys]. The organization monitors the quality of its worklife culture using the Worklife Pulse Tool. Number of times unmet Surveyors observed that some organizations have no formal processes to monitor staff fatigue and stress levels which can cause safety risks: Decreases were made to the nursing hours of service. The nursing staff is concerned with the additional workload in a shorter shift and want to ensure that a full evaluation is completed on the changes and resulting impact to worklife and stress levels. Surveyors also noted the importance of developing specific action plans based on results from worklife surveys: There was no specific action plan resulting from the worklife survey. This would be an important area to emphasize from the perspective of engaging staff in a focused manner around workplace culture. Effective January 2016, organizations are asked to submit an action plan to address the results of the Worklife Pulse Tool (WPT) 4 or an approved substitute survey tool. 4 The Accreditation Canada Worklife Pulse Tool provides a quick snapshot of key work environment factors, individual outcomes, and organizational outcomes. For more information on the WPT see page 12. 8

11 The Workplace Violence Prevention ROP A key part of the Accreditation Canada on-site survey is determining whether organizations meet the ROPs. First introduced to the accreditation program in 2005, ROPs are evidenceinformed practices that address high-priority areas central to quality and safety. ROPs are developed with input from health care experts including practitioners, researchers, policy makers, ministry of health representatives, academics, and health services providers at the provincial, territorial, and national levels. Each ROP contains a goal statement, a guideline with rationale and supporting evidence, and tests for compliance. Each test for compliance is rated during the on-site survey as met or unmet. An organization must meet all tests for compliance to be considered as having met the ROP. The Workplace Violence Prevention ROP requires that: A documented and coordinated approach to prevent workplace violence is implemented. The Workplace Violence Prevention ROP 5 was evaluated in 970 unique organizations 6 between 2011 and 2014, including 148 health systems, 144 acute care organizations, 277 long-term care organizations, 65 home care organizations, and 43 mental health organizations. Table 3 presents the number of organizations by sector and survey year. Table 3: Workplace Violence Prevention ROP Number of organizations by sector, Sector Number of organizations Aboriginal N/A Acute Care Health Systems* Home Care Long-term Care Mental Health Total** *Health systems in Alberta, British Columbia, Manitoba, Nova Scotia, Saskatchewan, the Northwest Territories, and Québec s Centres de santé et de services sociaux (CSSS) [Health and Social Services Centres]. **Total also includes independent medical or surgical facilities, medical imaging centres, and organizations providing assisted reproductive technology, community health, correctional, rehabilitation, respiratory and substance abuse and gambling addiction services, among others. 5 The Workplace Violence ROP can be found in the Leadership Standards, Leadership Standards for Small Community-Based Organizations, Leadership for Assisted Reproductive Technology Standards, Leadership for Aboriginal Health Services Standards, Medical Imaging Centres Standards, and Independent Medical/ Surgical Facilities Standards. 6 In some organizations where the Workplace Violence ROP was evaluated multiple times, these results include the latest evaluation year. Therefore compliance may differ from the annual national results. 9

12 As shown in Figure 1, overall compliance with the Workplace Violence Prevention ROP has decreased from 87% in 2011 to 81% in This indicates that workplace violence prevention must continue to be a focus of health care leadership. Compliance with the Workplace Violence ROP has been one of the lowest in the Accreditation Canada Qmentum program. Figure 1: Workplace Violence Prevention ROP Overall compliance by survey year, Compliance (%) As shown in Figure 2, compliance with the Workplace Violence Prevention ROP was highest in acute care and mental health organizations (94% or more in ) and lowest in aboriginal organizations and health systems (76% or less in ). In health systems, implementing ROPs throughout a wide range of service areas and organizations may prove more challenging which would explain lower compliance in these organizations. Figure 2: Workplace Violence Prevention ROP Compliance by sector, Compliance (%) Aboriginal (n=54) 94 Acute Care (n=122) 76 Health Systems (n=125) 91 Home Care (n=55) 81 Long-term Care (n=230) 95 Mental Health (n=33) 10

13 To meet the Workplace Violence Prevention ROP, organizations have to meet eight tests for compliance. As shown in Figure 3, the lowest rated tests for compliance (89%) were for organizational assessments to ascertain the risk of workplace violence, and for reviewing quarterly reports of workplace violence to improve safety and making improvements to the violence prevention policy. These two tests for compliance scored the lowest in health systems, 84% and 83% respectively. Figure 3: Workplace Violence Prevention ROP Tests for compliance, The organization's leaders review quarterly reports of incidents of workplace violence and use this information to improve safety, reduce incidents of violence, and make improvements to the workplace violence prevention policy. The organization conducts risk assessments to ascertain the risk of workplace violence The organization provides information and training to staff on the prevention of workplace violence. 91 The policy is developed in consultation with staff, service providers, and volunteers (as appropriate). 92 The policy names the individual(s) responsible for implementing and monitoring the policy. 94 The organization has a written workplace violence prevention policy. 95 There is a documented process in place for staff and service providers to confidentially report incidents of workplace violence. There is a documented process in place for the organization's leaders to investigate and respond to incidents of workplace violence Compliance (%) 11

14 Surveyors noted that a policy alone is not enough to make improvements in workplace violence and it is necessary to conduct a risk assessment, develop a formal process and documentation, and provide staff training for violence prevention: There has not been an organization-specific risk assessment related to the prevention of workplace violence that identifies the most probable risks in the workplace, allowing for appropriate measures and controls to be developed. Some organizations accomplish this through a combination of staff surveys with specific questions related to workplace violence, in combination with a workplace inspection that is specific to identifying hazards and risks for violence. There are pockets of excellent training for violence prevention but there were many sites visited that have not done any training or are even aware of where the policy currently stands. This needs to be addressed across all sectors. The Worklife Pulse Tool The quality of worklife is an important factor in the overall performance of health care organizations and impacts patient outcomes, productivity, and patient and worker safety (Lowe et al., 2010). Promoting a healthy work environment maximizes the capacity of staff to achieve organizational goals (Lim & Murphy, 1999). The Worklife Pulse Tool (WPT) has helped health organizations take the pulse of their worklife since it was included in the accreditation program in Results help organizations identify strengths and opportunities for improvement in their workplace, plan appropriate interventions to improve the quality of worklife, and develop a clearer understanding of how quality of worklife influences their capacity to meet its strategic goals. Following a comprehensive review in 2012, Accreditation Canada strengthened and streamlined the staff WPT into a 30-item questionnaire to provide client organizations with an evidence-based, easy-to-use tool that takes a snapshot of key worklife factors. Recognizing the unique relationship that physicians have with health care organizations and the importance of measuring worklife, a 22-item physician WPT was also developed. 12

15 The staff WPT is completed by leaders, support staff (administrative, clinical and facility), and direct care providers to gain a complete picture of worklife at all levels of the organization. Both the staff WPT and physician WPT measure key concepts organized by topic areas, including determinants and outcomes (see Figure 4). Although there are similarities between the staff WPT and the physician WPT, they differ significantly in the number of questions and topic areas (see Table 4 for a comparison by topic area). The staff WPT and the physician WPT both include items related to workplace safety, abuse, and violence. Figure 4: Components of the Worklife Pulse Tool DETERMINANTS JOB WORK ENVIRONMENT ORGANIZATION Autonomy Decision input Feedback Recognition Role clarity Role overload Skill use Respect Fairness Teamwork Communication Training & development Resources Safety Leadership Support OUTCOMES INDIVIDUAL OUTCOMES Job satisfaction Stress Worklife balance ORGANIZATIONAL OUTCOMES Engagement Quality 13

16 From 2013 to 2014, when organizations first used the revised tools, 62,853 staff respondents from 397 organizations completed the staff WPT, and 1,217 physicians from 53 organizations completed the physician WPT. Results are presented by topic area in Table 4. Table 4: Staff and physician Worklife Pulse Tool results by topic area, Positive response (%) Staff WPT Direct care Physician WPT Topic area (concepts) Support* n=20,865 to clients n=37,135 Leadership n=4,853 All n=62,853 Topic area n=1,217 Job characteristics (role clarity, role overload, decision input, autonomy, resources, recognition, skill use) Training and development (training and career development) Coworkers (respect, support, teamwork) Immediate supervisor (fairness, feedback, support) Safety and health (safety, worklife balance, job stress) Senior management (communication, leadership) Overall experience (quality, engagement, job satisfaction, engagement) *Administrative, clinical, facility Practice environment N/A N/A Colleagues N/A N/A Safety and health Senior leadership Professional satisfaction As shown in Table 4, 81% of staff positively responded 7 regarding their overall experience 8 and 79% of physicians positively responded regarding their professional satisfaction. Both topic areas measure overall satisfaction with one s job and the organization as a place to work. 7 Positive response is considered when respondents agree or strongly agree with an item in the WPT. 8 The overall experience score is an average of five items for the following concepts: quality (2 items), engagement (2 items), and job satisfaction (1 item). 14

17 The topic area of senior management received the lowest scores in both the staff and physician WPTs, 66% and 54% respectively. The staff WPT results show differing levels of workplace satisfaction by job category with support staff (administrative, clinical and facility) and staff providing direct care to clients reporting lower average scores across the topic areas. On average, physicians reported lower scores compared to staff. Figure 5 presents how staff and physicians responded to WPT items related to workplace safety and violence. 9 Results show that 73% of respondents agreed that senior managers are committed to providing a safe and healthy workplace, and 78% of staff agreed that their organization takes effective action to prevent abuse in the workplace. Eighty-four percent of staff agreed that the people they work with treat them with respect. Figure 5: Staff and physician Worklife Pulse Tool results, workplace safety and violence prevention items, My workplace is safe. 81 My organization takes effective action to prevent abuse in the workplace. 78 My organization takes effective action to prevent violence in the workplace. 80 Senior managers are committed to providing a safe and healthy workplace. 73 The people I work with treat me with respect Positive response (%) Figure 6 presents results for the WPT by job category. Physicians scores were found to be lower than those of staff. In particular, only 68% of physicians agreed that their organization takes effective action to prevent abuse in the workplace. However, most physicians (89%) agreed that the people they work with treat them with respect. The scores from staff working directly with clients, as well as those of support staff, were lower for workplace safety and violence items. Staff working directly with clients (76%) agreed that their organization takes effective action to prevent abuse in the workplace. Overall, support staff had the lowest scores for senior managers being committed to providing a safe and healthy workplace. 9 Note that direct comparison for the workplace safety and violence items for the staff WPT and the Physician WPT is possible with the exception of my workplace is safe which is not included in the Physician WPT. 15

18 Figure 6: Worklife Pulse Tool results by job category, My workplace is safe. N/A My organization takes effective action to prevent abuse in the workplace My organization takes effective action to prevent violence in the workplace. Senior managers are committed to providing a safe and healthy workplace Physicians Leadership Direct care to clients Support staff The people I work with treat me with respect Positive response (%) There was no correlation between the Workplace Violence Prevention ROP and the results for WPT items related to workplace safety and violence. Organizations that met the ROP had the same percentage of WPT positive responses as those that did not meet the ROP. 10 This analysis included 415 organizations where both the Workplace Violence Prevention ROP and the WPT were assessed from 2012 to This was examined using ROP compliance and the percent of positive responses for the five items related to workplace safety and violence in the WPT for each organization. These results were also confirmed by a Chi-square analysis operationalizing the Workplace Violence Prevention ROP as a variable with two categories: met and unmet. The WPT variable was constructed with three categories: neutral, negative, and positive responses. 16

19 Supporting organizations with program improvements and leading resources To support health care organizations across Canada in mitigating risks in workplace safety, Accreditation Canada continues to enhance the Qmentum program. For example, the Long-term Care Services Standards were strengthened (for assessment at on-site surveys beginning in January 2015), which included adding content in the areas of abuse and restraints. The enhanced standards require that abuse education and training is provided to the team, residents, and families. Organizations also need to follow an abuse prevention policy, as well as report and respond to alleged incidents of abuse. Significant revisions have been made throughout the program to strengthen and broaden client- and family-centred care, including in the Leadership Standards and the Workplace Violence Prevention ROP. This change reflects and promotes the need for meaningful involvement by client and families throughout the care process. These changes were released in early 2015 for assessment during on-site surveys beginning in January Accreditation Canada recognizes and shares Leading Practices in Canadian organizations across the care continuum. These practices are commendable examples of high-quality leadership and service delivery. Accreditation Canada also encourages organizations to share tools and guidance via the Resource Hub. Both the Leading Practices Database and Resource Hub are accessible through the Accreditation Canada website. By sharing a unique perspective on the safety and quality of health care services received by Canadians, Accreditation Canada continues to contribute to the performance of the Canadian health care system. 17

20 References Adams, S. (2012). NHS patients experience contempt and cruelty, says Jeremy Hunt. The Telegraph. Available at: Bujna E, Casselman N, Devitt R, Loverock F, Wardrope S. Leadership Engagement and Workplace Violence Prevention: The Collaboration between a Large Community Hospital and its Unions. Healthc Q. 2015, 18(2): Di Martino V. (2003). Relationship between work stress and workplace violence in the health sector. WHO. Geneva. Gillespie GL, Fisher BS, Gates DM. Workplace Violence in Healthcare Settings. Work (Guest Editorial). Kirwan M, Matthews A, Scott P.A., The Impact of the Work Environment of Nurses on Patient Safety Outcomes: A Multi-level Modelling Approach. Int J Nurs Stud (2): Léséleuc, S. Criminal Victimization in the Workplace. Ottawa ON: Statistics Canada Available at: Lim, S.Y., Murphy, L.R. (1999). The relationship of organizational factors to employee health and overall effectiveness. Am J Indus Med. (S.)1:64-5. Lowe, G.S. (2010). Using Common Work Environment Metrics to Improve Performance in Healthcare Organizations. Healthcare Papers. 10(3):8-23. Lundstrom, T, G. Pugliese, J. Bartley, J. Cox and C. Guither Organizational and Environmental Factors that Affect Worker Health and Safety and Patient Outcomes. Am J Infect Control (2): Ontario Nurses Association ONA Dialogue Issue Featuring Workplace Violence and Abuse Data Collected in 2009, Toronto, ON: Ontario Nurses Association. Ontario Nurses Association Workplace Violence and Harassment: A Guide for ONA Members. Available at: GuideViolenceHarassment_ pdf. Quality Worklife Quality Healthcare Collaborative. (2007). Within our Grasp: A healthy workplace action strategy for Success and Sustainability in Canada s Healthcare System. ( Accreditation Canada). Registered Nurses Association of Ontario (2009). Preventing and Managing Violence in the Workplace. Registered Nurses Association of Ontario. Available at: preventing-and-managing-violence-workplace. Yardley, J.K., Noka, M. (2005). Psychometric Quality Standards of the Healthy Hospital Employee Survey ( HHES). Internal Technical Report. Brock University; Ontario, Canada. 18