Threat Assessment and Management Teams

Workplace violence is a growing concern in healthcare organizations. For many years, regulatory and accreditation bodies have recommended or required healthcare workplace violence prevention programs. These programs typically include environmental and patient violence risk assessments, de-escalation and behavior management training and education, active shooter drills, and incident reporting and evaluation.
 
Violence perpetrated by patients with behavioral health disorders is nothing new—especially in emergency departments and behavioral health settings. But other risks to healthcare workers are emerging. The FBI reports that active shooter events in the United States rose by more than 50% in 2021. Similarly, the incidence of threats and armed violent attacks against healthcare workers from outside the organization has also increased. According to the Department of Homeland Security, hundreds of hospital-related shooting incidents transpired between 2000 and 2017. The following are a few alarming examples: 

• On November 19, 2018, a shooting at Mercy Hospital and Medical Center in Chicago took the lives of an attending physician, a police officer, a pharmacy resident, and the perpetrator. The incident began in the hospital parking lot when the gunman, who was the physician’s ex-fiancé, demanded she return an engagement ring.
• On June 30, 2017, a disgruntled physician concealing a rifle beneath his lab coat walked into the Bronx-Lebanon Hospital Center in New York City. He killed another physician and wounded six other people before shooting himself. The gunman had worked at the hospital for about six months before accusations of sexual harassment prompted his resignation.
• On February 9, 2021, a former patient opened fire and detonated bombs at the Allina Health Care Clinic in Buffalo, Minnesota, resulting in the loss of one life and injury to four others. 

Threat assessment (TA) teams are one way healthcare organizations can assess and manage potential violence from persons making implied or specific threats toward employees. To understand the role of a TA team, it is important to understand the differences between violence risk assessment and TA.

Violence risk assessment is a method of predicting violence in an individual based upon the prevalence of general/impulsive violence in certain populations and on individual characteristics that often correlate with violent behaviors. Hospitals often perform this type of risk assessment during emergency department and behavioral health unit encounters or patient assessments to evaluate a particular patient’s immediate risk for violence.

Threat Assessment is a behavior-based process developed by the U.S. Secret Service to assess threats against public officials. After analyzing violent incidents, researchers found that although typical risk factors for violence were not always present, predictable patterns of thought and behavior preceded violent acts, including difficulty coping with loss or failure, exhibiting strange behavior, being bullied or persecuted, and having access to weapons. 

Similarly, an analysis of active shooter events in healthcare indicates that perpetrators had often provided clues in statements or complaints made to others or exhibited concerning behaviors. Threat assessment may be helpful in situations involving:

• Patients or families who state or imply threats.
• Patients or families with unresolved grievances.
• Employees in distressing intimate partner situations.
• Employees who are disgruntled or have been terminated. 

An analysis of active shooter events in healthcare indicates that perpetrators had often provided clues in statements or complaints made to others or exhibited concerning behaviors.  Dr. Lynn Van Male, Ph.D., CTM, director of the U.S.’ largest integrated health system’s workplace violence prevention program, states, “People do not just snap. Instead, people progress along a pathway to violence through discreet stages that are behaviorally identifiable. It very well could be that someone is on a pathway towards violence.” She believes that assembling a multidisciplinary team is the best approach to assess and manage behavioral threats in healthcare and recommends including team members with security or law enforcement expertise, and behavioral science, human resources, risk management, and privacy law (HIPAA) backgrounds. 

Components of a TA  

• Identify a person who may pose a threat. Implement a process for employees to report any perceived or actual threats that cause concern for potential violence.
• Investigate the person. Once employees report concerns, convene the TA team to investigate the person to evaluate whether the person poses an actual threat to others.
• Evaluate the threat.  Determining whether a person poses a threat by considering risk and protective factors. This is similar to evaluating suicide risk, only that the violence is directed at others instead of the self. Factors that increase risk of threat include social isolation, hopelessness, and chronic or terminal illness. Protective factors might include connection with a therapist, a good social support network, and religious convictions against violence.¹
• Implement a plan. If the team determines that the person poses a threat to others, the approaches for mitigating the threat should be based on its perceived severity and imminence. The approach taken could be confrontational (arrest, mental health hold, restraining orders) or supportive/therapeutic (working with the person to increase protective factors and/or decrease risk factors).¹ 

Risk Management Recommendations: 

As violence in the workplace continues to escalate, the TA team is a concept that is rapidly gaining traction in the healthcare setting. Consider the following as important factors to include when implementing a TA team at your facility:

• Establish a multidisciplinary TA and management team. Include risk management law enforcement and security professionals, behavioral science experts, legal, and privacy officers as part of a comprehensive workplace violence prevention team. 
• Enlist employees. Educate and empower employees to report all perceived or verbalized threats through incident reporting systems or directly to a TA team member.
• Evaluate, investigate, and manage perceived threats. After identifying an actual or perceived threat, the TA team should promptly investigate and evaluate the situation to determine if the threat is valid. If so, work with local law enforcement agencies to develop and implement a plan to address and manage the threat.
• Be alert. Recognize warning signs of potential violence in staff, visitors, patients, contractors, students, and volunteers. These include:
  • Implied or stated threats.
  • Erratic or aggressive behaviors.
  • Changes in work quality.
  • Sudden personality changes.
  • Stalking or harassing staff members.
  • Statements of retribution.
• Provide continuing education to team members. Consider having at least one team member join the Association of Threat Assessment Professionals for networking and educational opportunities.

There is no indication that healthcare workplace violence events will decline soon. A structured TA and management team approach can provide early recognition, evaluation, and management of threats before they result in tragedy. 
 
References:

1. Ryan S, Thrasher T, Van Male L, et al. Threat assessment & management with a healthcare focus. Oral presentation at: Medical College of Wisconsin Risk Management Seminar. November 2022; Kohler, WI. 

Additional Resources:

• International Association for Healthcare Security and Safety Foundation
• Association of Threat Assessment Professionals