EXECUTIVE SUMMARY
With violent incidents on the rise in the hospital setting, patient access departments are taking steps to protect registration staff, such as providing de-escalation training. Other approaches include:
- reducing the number of public entrances;
- adding “panic” buttons to phones to allow patient access to alert security;
- creating role-playing exercises to defuse common tense situations.
A man entered a hospital outpatient center by shooting down the door, then headed to the cardiac ICU.
“He committed suicide when the SWAT team arrived, but had held several nurses hostage for a few minutes before the situation was handled by police,” says Sara Smiley, who was the hospital’s patient access director at the time.
Around the same period, a patient set himself on fire at the ED registration desk.
“Patient access staff were obviously affected by these incidents,” Smiley recalls.
Since the hospital provided both adult and pediatric psychiatric services, many staff were certified to provide Critical Incident Stress Management training.
“This was vital after the gun violence incident,” Smiley says.
Understandably, patient access employees were worried about their safety. Some asked for additional protections at registration areas, such as bulletproof glass.
“Many changes were put into place immediately,” Smiley remembers. “Panic” buttons were added to phones, so registrars could alert security of a problem within seconds.
“The hardest challenge for patient access is trying to balance providing superior customer service with ensuring safety,” says Smiley, currently a process improvement consultant for Experian Health.
Many hospitals have decentralized registration, which means there are many entrances — all open to the public.
“This was the case with our facility. We had many public entry points, and not all of them were staffed with security guards,” Smiley says, noting the hospital closed several entrances after the violent incidents. “All patients and visitors now enter through one of a few doors, all of which have security staff.”
During her frequent site visits, Smiley often is surprised at the lack of security in place.
“It’s kind of surprising how many hospitals just point us in the right direction, and that’s it,” she says. “There is a huge variety in the levels of security hospitals provide. There doesn’t seem to be a standard.”
Registrars Need Tools
Violence in hospitals clearly is increasing nationwide.
“Registration areas are no exception. These front-line personnel often get the brunt of a patient’s, family’s, or friend’s frustration,” says Richard D. Roebuck Jr., BAAS, CHPA, MPO, captain of police for the Dallas County Hospital District Police Department, based at Parkland Health & Hospital System.
Roebuck says threats of violence and physical assaults are a concern that demand “vigilance, training, and sensitivity. Registrars are in a unique position to encounter these situations.” Already-anxious ED patients lacking proper patient identification needed for registration sometimes take out their frustration on the person in front of them.
“Often the customer lashes out in an attempt to move the process faster,” Roebuck says.
The registrar’s three-fold challenge is to stay calm while providing excellent service, always with their own safety top of mind.
“It is a good idea to train all front-line employees on how to remove themselves from a volatile situation and not allow it to escalate to threats of violence or actual violence,” Roebuck says. (See related story on de-escalation training below.)
Roebuck says de-escalation training “is always a good idea. It puts a few tools in the registrar’s tool box on how to handle unruly customers, reducing the potential for violence or assaults.”
Reach Out to Hospital Experts
Mary Lee DeCoster, a Phoenix-based revenue cycle consultant, offers these suggestions for patient access leaders:
- Reach out to other departments to provide safety awareness training at regularly scheduled staff meetings.
Organizational development, education, security, social services, pastoral care, and compliance are good contacts.
“Training topics can be modified to fit the agenda and available time,” DeCoster says.
Some examples include safety awareness, recognizing when a patient is agitated, how to defuse a tense situation, hospital policies involving active shooters, and diversity training.
- Allow time and space for an individual employee to decompress after a difficult patient encounter.
Registrars can spend a few minutes in a nearby conference room, break room, a leader’s office, or a nearby restroom, for instance.
- Encourage co-workers to be alert for signs of potential conflict.
“Co-workers can move in to partner with the affected registrar, and function as a third party to defuse rising tensions,” DeCoster suggests.
A colleague can interrupt the registration interview in several ways, based on personal observations of the ongoing or escalating conflict. Some examples: “Hello, my name is Mary, may I offer assistance?” “It sounds like I might be able to help, if you will allow me to do so?” “Would you like something to drink? I can provide you with some water.” “I work with Mary, and believe I can help resolve this issue.”
“The words used should reflect respect for the coworker, while inviting the customer to turn their attention to them for additional support,” DeCoster says.
SOURCES
- Mary Lee DeCoster, Revenue Cycle Consultant, Phoenix. Phone: (602) 689-2026. Email: [email protected].
- Sara Smiley, Strategic Services Consultant, Experian Health. Email: [email protected].
Tips to Defuse Tense Situations
After several violent incidents occurred, registration staff at a behavioral health facility received de-escalation training. The focus was how to resolve conflicts that arise frequently in patient access areas.
“We wanted them to be able to avoid that initial escalation in the first place,” says Sara Smiley, who was the patient access director at the time. “If the issue was something they could resolve on their own, we empowered them to do that.”
If the registrars feel unable to resolve a concern, they must know the appropriate person to contact. For instance, registrars might contact the charge nurse if a patient is upset about a prescription, or involve the office manager for complaints about scheduling.
Smiley made a point of encouraging her patient access staff to be confident in a decision to call security or police. Sometimes, it can be a tough call for registrars to make. Some worry it will become a “he said/she said” situation, with possible repercussions from leadership.
To head off such concerns, Smiley says, “we reiterated that verbal abuse or violence of any kind would not be tolerated — and that it would never be incorrect to call for help.”
As patient access leaders, Smiley says, “We should trust their judgment. We should have their backs.” Here are three role-playing scenarios the department used during de-escalation training:
1. A patient (or parents of a patient) wants to see a nurse or physician, but they don’t have an appointment.
An effective response: “I understand that you don’t have an appointment but your situation is urgent, and that you need to be seen. I’ll be back with you as soon as I can.”
2. A patient is upset because a physician is running behind schedule, and their wait is longer than expected.
“My appointment was at 3:00, and it’s now 4:00. What am I still doing here?” The registrar might be tempted to tell the angry patient, “It’s not our fault! The lab is short-staffed,” or “There’s nothing I can do.” Such responses are a bad choice of words.
Instead, Smiley suggests saying: “I understand you have been waiting at least an hour. I know how frustrating this can be. I will check with the nurse to find out the best estimate we can give you.”
3. A patient is given a prescription, then finds out from the pharmacy that their insurance won’t cover it.
This often happens because the patient’s coverage changes from one Medicaid HMO to another with a different formulary.
The patient receives a refill, but no one realizes the new insurance won’t cover the medication.
In this case, Smiley suggests saying: “I’m sorry to hear your insurance doesn’t cover the prescription you’ve been taking for several months. We will try to get you moved to a different prescription that is covered by the new plan. If doctor says you cannot change medications, we will help you explain that to the new Medicaid plan.”
Registrars often bear the brunt of patients’ frustration.
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