On April 17, the Joint Commission—a nonprofit organization that provides accreditations to health care organizations—issued a list of seven steps hospitals should take to improve safety and reduce the risk of workplace violence perpetrated by employees, patients, and visitors. While the seven steps are advisory rather than mandatory, health care organizations risk jeopardizing their accreditation status if they fail to take appropriate action in response to episodes of workplace violence.

The Joint Commission’s alert seeks to address what it characterizes as the prevalence of workplace violence in the health care industry, citing a 2015 report from the federal Occupational Safety and Health Administration (OSHA) suggesting that approximately 75% of workplace assaults reported annually occur in health care and social service. The Joint Commission suggests that health care workplaces are particularly susceptible to workplace violence because of the daily care of patients dealing with mental health issues.

In the last few years, OSHA has taken action to address workplace violence in health care settings, including by overhauling its Guidelines for Preventing Workplace Violence for Healthcare and Social Service Workers, and by issuing citations to health care employers with allegedly inadequate workplace violence programs. Yet OSHA has not proposed an explicit regulation applicable to workplace violence in health care and instead has relied upon the General Duty Clause when issuing citations. And as our colleagues have reported, as of April 1, 2018, California is the only state that expressly requires all health care facilities to maintain a comprehensive plan to prevent workplace violence. The Joint Commission’s recent alert now adds additional incentives for health care organizations to implement and update workplace violence prevention programs.

So what can health care organizations do to protect the workers who put themselves in harm’s way each day? According to the Joint Commission, organizations should clearly define the term “workplace violence.” Staff members should recognize that workplace violence comprises a broad range of behaviors, from verbal assaults to physical violence with or without use of weapons. Staff should be able to easily report episodes of workplace violence, and organizations should track and follow up on any reported incidents, providing support and psychological counseling to victims, witnesses, and others affected.

Once organizations begin tracking incidents, they should review and analyze the data to identify common contributing factors and use those to develop intervention strategies. These strategies may include changes to the physical environment, such as altering exit routes, improving alarm systems, adding restricted access doors, and implementing more regular security patrols, or altering work practices or administrative procedures, reducing stressors like crowding and wait times, identified as risk factors for workplace violence. Organizations should train employees on how to use de-escalation tactics, and run practice drills such as active shooter response simulations. Finally, organizations should regularly review and assess the effectiveness of their responsive strategies to recognize areas of success and ensure continuous improvement.

While these measures are unlikely to completely eliminate workplace violence in health care settings, they represent a step in the right direction toward managing the risks, thus enabling our health care workforce to focus on the business of healing. Health care employers are well-advised to consult with counsel to develop and implement effective workplace violence prevention programs to improve employee safety and morale, reduce the likelihood of receiving an OSHA citation or jeopardizing accreditation, and – in the case of California employers – comply with the law.

The United States is in the midst of an unusually lethal flu season, and health experts agree that despite inconsistencies in their effectiveness, flu shots are among the best ways to fight the spread of the flu. A recent holding from the Third Circuit Court of Appeals provides some good news for health care employers who require that their patient-facing employees receive flu shots, making it more difficult for employees to claim a religious exemption.

Courts have held that health care employers may require their patient-facing employees to be vaccinated against a number of diseases, including the flu.  Whether employers can mandate vaccinations for all employees has been a closer question.  A key issue faced by employers is determining whether an employee’s anti-vaccination beliefs qualify for a religious exemption.

In Fallon v. Mercy Catholic Medical Center, the Third Circuit considered the religious exemption, clarifying what may qualify as such. Paul Fallon, a psychiatric crisis intake employee of Mercy Catholic Medical Center (“Mercy”), refused to get his required annual flu shot. Fallon had successfully asserted a religious exemption for several years before Mercy changed its policy to require that employees seeking such exemptions provide a note from a clergy member. Fallon, who does not belong to a religious organization, did not provide the clergy note, instead outlining his “sincerely held beliefs” opposing the vaccine in a 22-page essay. Mercy determined that Fallon’s beliefs, however sincere, were not religious. It did not grant the exemption, and subsequently fired Fallon when he continued to refuse vaccination. Fallon sued Mercy for wrongful termination alleging religious discrimination and a failure to accommodate in violation of Title VII of the Civil Rights Act of 1964.

The District Court sided with Mercy, and the Third Circuit affirmed the decision. The court relied on the three-part modern definition of religion, as adopted in Africa v. Commonwealth of Pennsylvania, 662 F.2d 1025, 1032 (3d Cir. 1981): a religion (1) addresses fundamental and ultimate questions having to do with deep and imponderable matters; (2) is comprehensive in nature, consisting of a belief system as opposed to an isolated teaching; and (3) is often recognized by the presence of certain formal and external signs.  The court concluded that Fallon’s belief that “the flu vaccine may do more harm than good” amounted to nothing more than a concern about the health effects of the vaccine and demonstrated his disbelief of the scientifically accepted view that it is harmless to most people.  Therefore, Fallon could not meet either of the first two prongs of the Africa test.  In addition, Fallon was unable to meet the third pong because he could not demonstrate that his beliefs manifested in “formal and external signs,” such as services or the existence of clergy.    Accordingly, the court concluded that Fallon’s “beliefs do not occupy a place in his life similar to that occupied by a more traditional faith,” meaning that “[h]is objection to vaccination is . . . not religious and not protected by Title VII.”

While the court’s decision provides guidance for employers responding to anti-vaccination beliefs, the court recognized that anti-vaccination beliefs can be part of “a broader religious faith.”  Thus, employers should be mindful not to categorically deny all requests for religious exemptions based on anti-vaccination beliefs.

Employers also should follow the recent developments within the Department of Health and Human Services (HHS), which recently established a new Conscience and Religious Freedom Division in the Office for Civil Rights (OCR) and released a proposed rule that would provide protections for health care workers who refuse to participate in services that run counter to their religious beliefs or moral convictions.   In an HHS press release on January 19, 2018, Acting HHS Secretary Eric D. Hargan said that the creation of the Division constitutes “a rollback of policies that had prevented many Americans from practicing their profession and following their conscience at the same time,” adding that “Americans of faith should feel at home in our health system, not discriminated against.”  These developments, and the public comments by HHS officials, may signal a move to prevent employers from enforcing mandatory flu vaccination policies.

Valerie N. Butera
Valerie N. Butera

The Occupational Safety and Health Administration (“OSHA”) recognizes that the health care industry is among the most dangerous in the United States (see related story).  Health care employees are more likely to be exposed to various infectious respiratory illnesses spread through airborne and droplet routes, such as tuberculosis, influenza, and pandemics.  Employees who work in or near areas where there are patients suspected of having a disease that can be spread by airborne transmission should be using proper respiratory protection to minimize exposure of airborne diseases.

In March 2016, the National Institute for Occupational Safety and Health (“NIOSH”) published the results of a multi-year surveillance study examining the efficacy of respirator use in health care facilities where airborne transmission of diseases is likely.  The findings of the study are alarming – evidence collected during the study indicated gaps in hospitals’ respiratory protection policies and wide-spread failure by health care employees to use respirators correctly, even in hospitals with effective respiratory protection programs.  More specifically, the NIOSH study revealed that many employees were confused about when to use a respirator and how to properly use one and opted to simply use a surgical mask for protection instead.  But respirators and surgical masks are designed to protect against very different hazards.  Whereas a surgical mask protects patients from an employee’s respiratory secretions and protects employees against large-droplet splashes or spray of bodily fluids from patients, a respirator is designed to protect employees by providing a tight seal against the skin and filtering out a wide size range of airborne particles.

The study also found that a number of employees wore ill-fitting respirators.  To be effective, the wearer of a respirator must wear one that minimizes air leakage into the facepiece.  OSHA regulations require respirator fit testing before an employee is permitted to wear a respirator.  Because the fit of a respirator depends on a number of different factors, such as face shape, employers should provide a variety of models and sizes to try during the fit testing process.  Fit testing must be repeated annually, when a different respirator must be used, and where there has been a change in the employee’s facial structure such as extreme weight loss or dental work.

Finally, about 50% of the hospitals studied were deemed to have ineffective respiratory protection programs.  But even where good programs were in place, many employees used improper practices, including improper strap placement, failing to perform a user seal check, and improper donning and doffing of the respirator.

So how can health care employers correct this issue before tuberculosis or the next pandemic hits?  Employers should ensure that:

  • their current respiratory protection policy is compliant with OSHA regulations, CDC guidance, and any additional public health requirements in their jurisdiction;
  • all employees working in areas where they may exposed to airborne illnesses have been timely fit-tested for a respirator and understand how and when to use it;
  • training on respirator use, fit, and how to properly don and doff the respirator has been provided and periodic refresher training scheduled;
  • employees check their respirators regularly and know to immediately report to management should the respirator begin to deteriorate, fail to function properly, or no longer fit well; and
  • employees receive new fit tests and respirators as needed.

These simple steps will help ensure the health and safety of employees and patients when the next airborne infectious disease infects your hospital.