William S. Marcisz, JD, CPP, CHPA
Healthcare employees will fear for their safety if an organization lacks a strong process for screening and identifying visitors or fails to follow the existing process strictly.
My security consulting firm frequently receives inquiries from hospital administrators wanting to implement security measures that will make healthcare workers feel safe. We all know why healthcare employees fear for their safety. Hospitals experience a high rate of workplace violence. During the pandemic, aggressive behavior intensified over issues relating to restrictions on visitation and safety-compliance measures, such as mandated temperature screening and mask wearing. In 2022, there were several high-profile shootings and stabbings in hospitals in which nurses and physicians were victimized. In many hospitals, an all-consuming fear has lead hospital employees and physicians to openly question their administration about the security and safety measures they perceive should be in place.
Often, hospitals turn to expensive solutions, such as armed security officers, off-duty police, or metal detectors. Although these security measures may well be indicated at certain hospitals, they will make staff feel safe only temporarily. Eventually, the staff will come to realize that off-duty police or an armed security force does little to deter or address aggressive behavior from patients and guests unless that officer is present. Regarding metal detectors, staff perception of safety will be undermined the first time a weapon slips through or a weapon is improvised from tools or equipment from within the hospital. In my work, I do not discourage hospitals from implementing these security measures when warranted, but other effective and less costly methods can enhance safety while also reducing staff fear of violence. One obvious but overlooked safety measure that can meet these goals is effective visitor management.
THE BENEFITS OF VISITOR MANAGEMENT
Incidents of crime or workplace violence in hospitals are caused by people. The more people in your hospital, the greater the risk of a violent occurrence. Among the top hospital staff concerns for safety are people in the facility who are not identified as having permission to be there. Hospitals have long required employees, physicians, and vendors to wear ID badges, and patients are easily identified by wrist bracelets. But a person in the hospital without a visitor badge or sticker raises suspicion. Staff frequently ask themselves, “Who is this person, and do they belong here?” These instances increase staff anxiety, particularly at night when the facility’s perimeter is supposed to be locked down and relatively few people are around. Fear of riding in an elevator alone with a stranger increases exponentially when that person is not wearing an ID badge.
In the ideal world, a visitor management process includes the following elements:
- Accountability. Identification of who is in the facility.
- Security. Screening out the entry of persons who have no business within the hospital—specifically, criminals or others who could create risk and liability for the organization.
- Threat identification. Detection and denial of entry by persons who may have issued a threat against the hospital, an employee, patient, or physician.
- Compliance. Meeting the accreditation standards—and best practices—calling for identifying all persons within your hospital.
- Safety. A solid visitor management process makes everyone feel safe.
Clearly, accountability is extremely important. When hospital staff, patients, and guests know that all persons in the hospital have gone through a screening and identification process, everyone is reassured there are “no strangers among us.” This reassurance increases the perception of safety.
If a hospital does not screen and identify visitors and guests, the lack of an identification process could be one reason that staff at the facility do not feel safe. But having a system is not enough. For staff, the only thing worse than not having a process for identifying visitors is having one that can be defeated easily. Staff members know where the process gaps are and how people can circumvent being screened. Awareness of these flaws can make them feel unsafe.
What generates fear when hospital staff see a person without an ID badge is not strictly that the person is unidentified. Rather, it is the potential or perceived risk that the unidentified guest represents. An ID badge that has been properly issued makes people inside a hospital feel safe. The ID badge essentially makes the following the three statements:
- “I belong here. Today”
- “I signed-in at the front desk. Today”
- “I have permission to be here. Today”
The ID badge not only establishes an environment of accountability but also adds value in terms of employee satisfaction if they feel safe at work. A solid visitor management process leaves employees with an impression that their hospital administration cares about everyone’s safety.
Thus, it is not necessarily the fact that screening and badging are being done that makes employees feel safe, it is their confidence that the process is being followed. The stronger the process is, the greater will be the level of confidence in the organization’s security. When staff feel safe, the feeling will help with employee engagement. When staff feel safe, they are less distracted by fear of violence. When staff and physicians can work without fear or distractions, the likelihood of medical errors resulting from distraction goes down.
SIX CRITICAL ELEMENTS
When it comes to screening and identifying visitors and guests, the following six elements are required. The elements are quite simple; however, if any of them are missing, the entire visitor management process will eventually be undermined, breakdown, and fail. The elements are:
- Secured hospital perimeters
- Screening and badging
- Vigilant enforcement
- A culture of safety
- A written policy
- Training and education
- Secure Hospital Perimeters
An effective visitor management process begins with securing the hospital’s perimeter such that no visitors or guests can bypass the screening process. Once the building perimeter is secure, visitors and guests should be directed or funneled to entrances where they can be screened quickly and efficiently.
If perimeter security is easily breached, hospital staff will see little value to screening visitors or enforcement of the hospital’s policy. This in turn will make employees less engaged and less willing to take ownership and be part of the solution. If a hospital refuses to lock all entrances at night, or security fails to secure doors that are regularly found open, these omissions increases staff perception of a leaky perimeter and undermine faith in the visitor management process.
Screening and Badging
Screening is one of the most important steps and must be done by personnel who are attentive and skilled at customer service. Screening of guests and visitors requires the hospital to identify the person trying to gain entry and validate that they have a legitimate purpose for being in the hospital. In most cases, the person needs to show a driver’s license, passport, or a state-issued identification card.
The next step is to verify that the patient they are trying to visit has been admitted to and is present in the hospital. If the patient has been discharged or has never been a patient, access should be denied.
The screening process also involves attending to restrictions that have been placed on visitors. A patient may have requested that certain people not be allowed to visit. In addition, some hospitals have limits on the age of visitors, or the number allowed to visit a patient at a single time.
Finally, if the visitor is listed on a sex offender registry, this listing could preclude visitation or cause hospitals to permit only supervised visitation. Most visitor management software or platforms can keep a running tally of the number of visitors who are already checked in and can tie into criminal or sex offender registries that will flag offenders. These systems can in many cases allow a hospital to create BOLOs (Be On the Look Out) for persons who are unwanted, have predetermined visitation restrictions, or have already been trespassed from the facility.
Two kinds of screening failure are common. First, success can be undermined if it takes place at a location that can allow unwanted people to bypass the screening process and gain entry to the hospital without being identified. The process can also fail if screening is performed inconsistently or not at all in some locations. The second problem can arise if staff are untrained and therefore do not do the screening properly. Another issue arises when the screening function is assigned to hospital staff who may be too busy with their primary job, as can be the case with patient financial services staff, emergency room triage personnel, unit clerks, or security officers responsible for monitoring or dispatching services. A screening processes that relies on staff who are burdened with other tasks is one designed to fail.
As is true in the case of unsecured perimeters, seeing that the screening process has holes in it will frustrate those tasked with enforcement. Knowing that the process is not reliable will also creates dissatisfaction in the broader staff and feed into the feeling of not being safe. Moreover, these people are likely to grow tired of the added burden placed on them to make up for “other people not doing their job.”
To make screening faster and easier to manage, most hospitals now use electronic visitor management systems. Systems can be interfaced with patient registries. These systems collect visitor information from a driver’s license and can instantaneously populate a visitor ID badge with their name, the unit they will be visiting, and the anticipated length of time they will be staying. Many hospitals color code ID badges by day or certain units, thus letting employees know whether the person is authorized to be in the vicinity and that their badge is current. Because some people will retain previously issued ID badges and attempt to use them to regain entry another day. I suggest using badges that expire overnight and fade so that staff can easily detect someone circumventing the process. Many systems can screen sex offenders from state registries or flag unwanted guests.
Vigilant Enforcement
Enforcement may be the most overlooked aspect of visitor management. Purchasing a sophisticated electronic visitor management system that can quickly screen persons entering the facility and choosing smart locations to issue badges is not enough. The “enforcement” aspect of visitor management must come into play whenever a staff member finds someone in their area without an ID badge. In other words, strong visitor management requires vigilant participation from all staff, who should feel responsible for ensuring that everyone is properly identified. It is important to note that unless staff are empowered and invested in their own safety, they may not all step up and act to enforce the hospital’s visitor management policy. The organization’s leadership bears responsibility for this attitude. The most effective way to facilitate ownership of the visitor management process is for the organization to have or create a culture of safety.
A Culture of Safety
When an organization has instilled a culture of safety, staff will become engaged and take responsibility for the safety of their environment. By contrast, in many facilities, staff or even administration place the entire burden of organizational safety on the shoulders of the security department. It is unrealistic to expect the security staff to track down each person who may have eluded the screening and badging steps in the visitor management process. Effective visitor management “takes a village”—that is, it requires participation from the entire organization. When a staff member in a hallway encounters a person without an ID badge and proactively steps in to intercept the nonidentified individual, and help them to get screened, this intervention creates a safer environment and takes some of the burden from the floor nurses, allowing them more time to provide patient care.
A Written Policy
The visitor management policy serves as a touchpoint for hospital staff to understand everyone’s responsibility in the visitor management process. Not all hospitals are alike, and visitation to certain units can vary. In addition, some facilities are too large or have a design that requires visitor screening and management to be conducted at individual units. Whatever process is best for a given facility, that approach must be administered uniformly, and the policy and procedures must be accessible in writing and readily referenced by staff.
Training and Education
Although the visitor management process is not difficult to learn, it does have a few moving parts. I strongly recommended that hospitals create a training module for all staff and physicians explaining the procedure and reinforcing that it is everyone’s responsibility to own security in their area. This responsibility includes managing visitors who may not have been screened and identified. Training modules reinforce the organization’s expectations for staff to “own” the safety and security for their work area. If delivered continually in a positive way, training on the visitor management process serves as a reinforcement to the hospital’s commitment to its culture of safety.
Hospital security and safety programs are multidisciplinary, requiring all staff to participate to some degree. Nearly all hospitals require a multi-layered security program to protect patients, staff, and guests. Visitor management is just one layer. However, when done correctly with all staff engaged, it will be a very effective tool to keep criminals and others who represent a threat to the environment out of the facility and to identify them more easily if they do breach the perimeter. And, by reducing the number of unidentified people in the facility, the facility should reduce a major source of employee fear.
