Patient and visitor violence against hospital staff is a real issue, considering that officials at the UK’s National Health Service (NHS) documented 55,000 reported incidences of physical assault against staff in 2007. The figure represents 4.2% of NHS’ 1.3 million employees.

Although hospitals have been traditionally perceived by the public as “safe havens,” this is now changing, according to Tony York, president of the International Association for Healthcare Security and Safety. Designers and planners can play a critical role in a hospital’s security operations—particularly by including the health system’s security professional from planning through construction stages.

Tony York, president of the International Association for Healthcare Security and Safety, speaking to security professionals at the Serious About Security—2008 Symposium held at the Cleveland Clinic in April. Image courtesy of Matrix Systems

York, senior vice-president at Hospital Shared Services, Denver, recently discussed trends in hospital security, as well as some approaches to design for a gathering of about 60 security professionals at the Serious About Security—2008 Symposium, sponsored by Matrix Systems, a Dayton, Ohio-based turnkey access control and security solutions provider.

The results of the recent acts of violence and terrorism in the transportation and education sectors have pushed heightened security in operations and design. York predicts that the healthcare sector is “one incident away” from moving in this direction, as well. Just this March, in Columbus, Georgia, an armed man entered Doctors Hospital and killed a nurse and an administrative assistant in the intensive care unit. “Personally, I think when you get into the design considerations, you need to realize we’re one incident away,” York says. “So in design, you need to be thinking about how you are going control that at the main entry.”

York’s Security Design Considerations for the Healthcare Market presentation at the symposium, held last April at the Intercontinental Hotel Conference Center on the Cleveland Clinic’s campus, focused on the most at-risk hospital space: the emergency department. York says that 60-70% of the time, the ED is the portal of access for the rest of the hospital, so controlling entry at this point is critical to the hospital’s security.

Considering the following trends, he suggests a design strategy that includes analyzing the patient population, compartmentalizing the ED, planning ahead for security retrofits, and including security professionals from design concept through to construction.

Violence trends in healthcare
Unavailability of acute psychiatric treatment. “Behavioral healthcare funding is absolutely drying up,” York says. “In our community in Denver, we’ve seen five hospitals close their doors that were primary mental healthcare facilities. All those patients are still out there. They’re trying to go to out-patient services, but what’s happening is they’re presenting themselves in the emergency departments with a higher acuity level, which means they typically have a higher level of ‘acting out’ behavior.”

Physical assaults. Earlier this year, while travelling in the UK, York spoke with nine of the officials collecting the NHS staff assault data mentioned above. Each one of them said that the 4.2% figure is underreported by a percentage of half.

“Out of 1.3 million, they think they have 110,000 reported assaults against staff,” says York. “We in the United States don’t know those numbers because we don’t have the same level of national reporting, but I am convinced we are seeing those same kinds of issues where roughly 10% of all staff members have some type of physical assault being committed against them.”

Weapons. York cited an American Hospital Association study that found that 5% of all persons entering a hospital have some type of weapon that can harm someone else. He also cited a four-year study conducted by the Henry Ford Medical Center, Detroit, reporting that 4% of persons arriving at the emergency department carry weapons. Considering these numbers, combined with its extremely emotional environment, long wait times, and its come-and-go, open environment, the ED may be the most at risk space for weapon violence.

Miscellaneous contributors. Wait times, overcrowding, and the lack of communication, including language barriers and illiteracy, contribute to the stressful healthcare environment. The results of gang violence, drug and alcohol abuse, and domestic and personal disputes get funneled to the ED, which adds unpredictability and irrational, emotional decision making.

Analyze the demographics
Understanding what services are being offered and the patient population being served in the planning and design stage is a critical component of security design, York says. The type of patient will drive the type of security. In suburbia, where much of the new hospital construction is happening, security may be “behind the scenes” and more focused on securing the perimeter than individual departments. Because of their patient mix, urban facilities may want to focus on creating an outward psychological deterrence and compartmentalizing the ED within its own security perimeter.

York also suggests that planners take a look at the time frame the project will serve that population and how the demographics will change throughout that time. A changing demographic will call for a changing security plan. For example, will you have to install walk-through metal detectors in the ED in the future? If there is a chance metal detectors will be needed, then it will be easier and cheaper to design the ED with this in mind upfront. Take into consideration where the detectors will be installed; how visitors, patients, and staff will be queued; and where confiscated and temporarily held items will be stored.

One useful planning tool is a crime forecast map of the campus’ surroundings. A crime forecast map, such as the CAP Index (figure 1), will depict the likelihood of an act of crime in an area. Crime forecast scores indicate the risk of crime at a site compared to a national average of 100 (i.e., a score of 400 means that the risk is four times the average and a score of 50 means the risk is half the average). Using the map, compare areas for risk of criminal activity, consider the likelihood of a criminal element straying onto the campus, and consider external components: where’s the parking, how is the lighting situated, is there fencing, how can landscaping affect pedestrian traffic flow?

Figure 1: Crime forecast maps, such as this one of the area near the Cleveland Clinic’s main campus, can help planners predict the likelihood of a criminal element straying onto campus. Crime forecast scores indicate the risk of crime at a site compared to a national average of 100. (i.e., a score of 400 means that the risk is four times the average and a score of 50 means the risk is half the average). Image courtesy of CAP Index, Inc.

The emergency department
Planners also need to consider how security design and operations will relate to how spaces will be used. In particular, what are the traffic patterns between the ED and other departments? Because the ED is the point of entry for the rest of the facility the majority of the time, York says to concentrate on controlling access there by securing its perimeter. Although he says as of yet there are no set best practices for ED security, “the community standard is the emergency departments are locked down and the medical treatment areas are secured from uninhibited entry.”

If compartmentalizing the ED, other frequented departments and spaces’ relationships to it will have to be considered. York suggests designing the radiology department within the ED perimeter. A radiology department outside of the compartmentalized ED is bound to create automatic breaches of the system, as staff alter and undermine the perimeter by propping open secure doors.

Another question to ask is will the registration desk be within the security perimeter? The question involves a balance of registration staff safety, aesthetics, and patient perspectives (do they feel like they’re entering into a courthouse or into a hotel?). Used by the banking industry, high counters for registration desks create psychological deterrence against patient and visitor violence against staff. Yet this must be designed in such a way not to alienate the patient and visitor.

The ED is typically the designated after-hours access point. York says to think about how to manage visitors and control the ED entrance after hours by integrating design and technology, such as cameras and buzz-ins in a queuing area and the use of magnetic swipe and proximity cards.

The main security question for the design team is: How do we control and flow traffic from the ED’s entrance to the rest of the facility? “This is a question you want to bring up at the design stage: How are you going to control it and at what doors? And then you have to make certain that you manage that throughout the rest of the organization,” York says.

Securing and compartmentalizing the ED can cause concern for doctors and nurses, who may feel like the security design will restrict their access and work flow. To get buy-in from the medical team, explain the security design in a value staff understands: The creation of a controlled work environment with limited visitors. “Who will the visitors ask assistance from? Who will they get in the way of? Be able to explain the value of this to the medical team,” York says.

Addressing the security professionals in attendance, York says, “Define your security design strategy upfront because something’s going to change between the time you have the first conversation, you give your markups, and the contractors finish the project. There’s going to be a wall change or some other change. And you have to be able to communicate to them your philosophy behind the design. I’ve been involved in enough of these and I know that these things will not communicate all the way down to you the entire way. And that’s part of the process you want to go through.”

Look for Part II of “Serious about security” next Monday, May 26. Take a photo tour of the Cleveland Clinic’s new state-of-the-art security command center, which was designed by the Clinic’s manager of Technical Operations—Protective Services.