← Becker’s Healthcare Podcast
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- [00:01]
A
This is Grace Lynn Keller with the Beckers Healthcare podcast. And I'm excited to be joined today by Dr. Raj Chand, who is the president at Inova Fair Oaks Hospital. Raj, thanks for being here today. Let's start by having you tell us a little bit more about yourself Inova, and your journey in healthcare leadership.
- [00:18]
B
Awesome, Grace. Well, thanks for inviting me to the podcast. I've been a longtime listener and excited to be here with all of you today. So, as you mentioned, my name is Raj Chand and I'm a healthcare executive. I'm also an emergency medicine physician and it's hard to believe. Now I've been practicing clinically for almost two decades and have over a decade of experience in healthcare leadership. I currently serve as the president of Inova Fair Oaks Hospital. And I'm really proud to share that Fair Oaks is one of the few community hospitals in the country to to be named a leapfrog top hospital five years in a row. That's something that we're very proud of. My clinical experience has shaped the areas that I'm most passionate about in leadership. Areas like workforce development, building high performing teams, and workplace safety. And then when I'm not at work, I try to squeeze in some orange theory workouts where I work. My second job, which is an Uber driver for my two teenage kids. So. So that's a little bit about me.
- [01:20]
A
Wonderful. Well, thank you so much for sharing. And could you tell us a little bit more about Inova?
- [01:26]
B
Absolutely. Nova Health System is located about 30 minutes west of Washington D.C. we are a five hospital system with more than 1800 licensed beds. We have 300 plus ambulatory sites, six and a half billion in revenue in 2024, and more than 25,000 proud team members. And since 2018, we have been on a transformation journey ever since Dr. Steven Jones joined us as our system CEO.
- [01:54]
A
Wonderful. Well, thank you so much. And now let's jump into kind of reframing the problem that you're here to talk about. So can you touch on some of the experiences or individuals that have shaped your focus on workplace culture and safety?
- [02:08]
B
Yeah, that's a great question and one that I've thought about a lot as I have stepped into this leadership role. And one moment that I will never Forget was almost 20 years ago, I was a senior resident in emergency medicine. I was working an evening shift, just like every other evening shift. And then all of a sudden I heard one of our behavioral health patients start banging on the door and then actually pound the door down, come out of the room and then tackle one of my co residents. And all of us who were there were just shocked. We jumped into action. We restrained the patient, medicated the patient, made sure he was okay, we made sure my colleague was okay. And then what was most notable to me now in this role is we just went about our normal business. We just accepted this. This was part of what happens in health care. There was no debrief, there was no type of after action review, no type of systemic change. And I actually realized I had not been trained to either recognize or respond to workplace violence. And so it really was normalized at the time. And so now fast forward 20 years, I'm really proud to be at Inova and I think I believe we have a very strategic, systematic approach to workplace violence. We have multiple tools for our team members. And while workplace violence has really increased over those two decades, I also believe our response capabilities have significantly improved. And we'll talk a little bit about some of the tools that we have.
- [03:43]
A
Absolutely. Well, thank you so much for sharing. And that segues us perfectly into this first topic of reframing the problem. What is the connection that you see between psychological safety and workplace violence?
- [03:56]
B
At inova, we have a set of principles that guide our daily work. We call them care imperatives. One of the care imperatives is we must create a culture of psychological safety that empowers each team member to fully engage. And for us, psychological safety is the foundation for both patient safety and team member safety. The easiest way that I can explain psychological safety is openness without fear. We want people to feel safe, to speak up. And in healthcare, that really is very, very important. Whenever I'm on a podcast, I always like to share some resources that I think can be helpful. There is a fantastic book on this topic called the Four Stages of Psychological Safety by an organizational psychologist named Tim Clark. He also has a phenomenal podcast that's called Leader Factor. For those who are looking to go deeper on that topic, my management team at Fair Oaks, we took about six months to slowly go through that book and try to understand some of those principles. Principles like inclusion, safety, learner safety, contributor safety, challenger safety. Ultimately, we believe that when people feel safe to share their experience, we will be better positioned to respond to workplace violence.
- [05:16]
A
Absolutely. That makes so much sense. How would you describe the current scope of the workplace violence you see in healthcare?
- [05:25]
B
Unfortunately, as I mentioned, health care is one of the industries that's most prone to workplace violence. I believe we have five times the rate of workplace violence compared to other industries, and 82% of nurses experience workplace violence at some time during their careers. There are a set of contributing factors that have really been amplified over the past several years. There's three in particular that I think of. One is just the broader societal polarization that we're seeing. Two is the pandemic really brought that all into stark relief and accelerated tensions and increased some of that polarization. Then three is just the workforce pressures. Our patients are more complex. There are greater time constraints depending on the environment that you're in. There can be resource limitations. So all of those things have increased the pressures on our workforce, which I think have also connected to workplace violence.
- [06:27]
A
Absolutely. And now let's kind of shift focus to the organizational response. And I'd love to know how INOVA Health System has approached workplace violence from a strategic perspective to help remedy these issues.
- [06:42]
B
We have been on this journey since 2018 to try to address workplace violence not with one off interventions or one off solutions, but really to think about it as an ecosystem and to take a really strategic systemness lens to this. So we have an ecosystem of solutions that we've tried to deploy. And there's four in particular that I think about. One is a philosophy around zero harm and that applies to both patients and team members. For so long we just accepted workplace violence as part of what it means to work in healthcare. And, and we now have a very different stance on that. We also second, we have a zero tolerance policy. So we have very clear boundaries for patients, for families and visitors. And visitor patients certainly, obviously have the most rights within a hospital system or healthcare organization. But we've been very, very mindful around making sure that we are approaching families and visitors and really setting limits around that. So that's some of our concepts around zero tolerance. Third is training and education. And as I mentioned in the example at the beginning, I had not really been trained in how to recognize the warning signs. I didn't know how to de escalate properly and how to respond when a workplace violence situation arose. So we have annual training, depending on the type of work that you do in the organization, around each of those things. Recognition, de escalation, response. And so that's another important component. And then fourth, and this has really been a shift as well, is engaging our physicians and apps in this work. Historically, this has been something that nurses have carried the mantle on and we're moving beyond a nursing only lens to include the entire multidisciplinary clinical team to address our challenges with workplace violence.
- [08:38]
A
Absolutely. And what are some of the tactical elements of this response that you're speaking of. And can you walk us through the specific tools and supports that you've implemented?
- [08:49]
B
Sure. Let's start out with some of the ones that I think are a little bit more widespread in the healthcare industry that we have and I imagine others have as well, tools like the Broset Scale, which is a standardized risk scoring system that we, that our team places an EPIC so that everyone has visibility around the risk of workplace violence with a given patient. We implemented a weapons detection technology at many of our entry points. Not every single one, but many of the key points have a weapons detection system there. And we've also implemented an armed officer program. So those three, I think are pretty widespread in the healthcare industry. They there are a few that are unique to anova, and I'll comment a little bit about those. Much of our focus has been on prevention. Kind of the ounce of prevention is worth a pound of cure idea. And so the first thing that I would say around prevention is we have two levels of response. Historically we would just have this kind of security assistance, which would be security would come in sometimes they would need to go hands on. But we now have kind of a much more nuanced response system. And we have what we call safe teams. So think of this as like a rapid response for workplace violence. And when anyone can activate a safe team, it brings about a multidisciplinary group who comes to the room, often includes two security officers. It'll include our administrative director, which in some organizations is called the nursing supervisor, brings the leadership team as well, so the senior directors there, the clinical director and the clinical team, the physician or the app that are involved in that care of the patient, and then that team huddles up. Because every patient is really unique. Every workplace violence situation is unique. And they'll determine what the best course of action is in terms of medications or setting limits or engaging others. So that's probably been our first initiative in terms of preventing workplace violence before it becomes very serious. The second, and this is something that I'm really proud of, it was a pilot that began at Fair Oaks Hospital is what we call the Workplace Violence Magnet Program. These are just as you would imagine, little yellow magnets that we place on the doors, the door frames of those patients who are at risk or violence. And what it does is what's pretty unique about it is it alerts all staff, not just clinical staff. And when you think about it, not everyone who works in the hospital has access to EPIC teams like environmental services, food services, transport, oftentimes they're not really interacting in epic, but when they see that yellow magnet, they know they're on heightened alert. We often ask and encourage people to have a buddy system so not to go into those rooms alone. And in the year plus that we've had this program, we've seen about a 10% reduction in physical events, which is pretty significant. And then the Joint Commission and the National Quality Forum, those organizations characterize any type of inappropriate physical contact as a sexual assault. And I'm proud to say we went from about 2 of those per year to 0 since this initiative went into place. So lots of really great progress. The workplace violence magnet, the third component of our response is what we call the administrative discharge policy. We talked a little bit about how we set limits with families and visitors, and that's much easier. We recognize that there's a subset of patients who often continue to act up or act in ways that are not in accordance with our values or how we want our team members to experience them. And so we go through a kind of three pronged approach with setting limits, engaging clinical leadership, and then ultimately we engage either the CMO or myself to administratively discharge patients from the hospital. And we certainly provide them with every. We provide them with medications and prescriptions and follow up resources, but we very much set limits. And the administration discharge policy has been very successful. Probably a dozen or more patients have been discharged through that pathway. And I think it creates a sense for our frontline teams that our leadership team has their back and supports them. Then unfortunately, no matter what we do, sometimes workplace violence events are going to happen. And we have a very robust chaplaincy program. We have an employee assistance program, and we also have something called the CARE peer support program. These are frontline team members who are specially trained. They go through about a four hour training and their function is really just to be present, to listen without judgment, with compassion. And it's not centered around problem solving, it's just what I mentioned, just listening and being there for your colleague. That often really goes a long way when there's a workplace violence event or some other type of adverse event that happens in the hospital. So a pretty robust framework that we have around addressing workplace violence.
- [14:13]
A
Absolutely. It sounds like you've done a lot of really great work to address and minimize these issues as we close out our conversation here. First, I'd love to know what leadership lessons you've learned throughout this work.
- [14:28]
B
I think there's three. That's a great question. One is recognizing that there are complicated problems and then there are Complex problems. So what do I mean by that? Complicated problems are things where there is a known problem, known solution, something straightforward, like building a car, you know, who you have to pull together and the set of steps to get to a functioning car. Workplace violence is not complicated. It is complex. It is multifactorial, it is unpredictable. There's lots of different players. And so I think the analogy I always have in my mind around complex problems is traffic jams. You never really know how it's going to emerge or how it ends. And so it requires a very different mindset. It requires an adaptive mindset and adaptive management. And it requires us not to have just one time fixes for these complicated, for these complex problems. The second leadership lesson that I've learned is what we talked about at the very beginning, really being a systems thinker around this and investing in an ecosystem of solutions when you have these multiple reinforcing interventions. I mean, we talked about probably close to a dozen interventions, large and small, during this conversation. And together those reinforcing interventions help us create sustainable change. Ultimately, that requires changing the culture and it really requires a lot of reinforcement because team members change. People forget the resources that are available to them. So having a very strong systems thinking lens on this is really important. And the last lesson that I would say is just one that I have learned over 20 years, which is reframing this priority. Team member safety is the foundation of patient safety. And I think when you take that seriously, frontline team members feel it. They feel supported by their leadership teams. And ultimately, I think there's better outcomes for patients and our team.
- [16:26]
A
Absolutely. Thank you so much for sharing that. And then my final question for you as we wrap up our conversation is what advice would you offer to other healthcare leaders facing similar challenges with workplace violence?
- [16:39]
B
The advice that I would offer to other leaders as they focus on this is this is something that has to be managed. It's not something that really goes away. And even though we have all of these tools in the toolbox, we unfortunately still grapple with workplace violence on a daily, if not weekly basis within our hospitals and care sites. This has to be a priority for leadership teams on an ongoing basis. It has to be part of the culture. And the culture really needs to shift in some of the ways that we've talked about for this to be a sustainable change for us.
- [17:18]
A
100%. Well, Raj, thanks so much for taking the time to speak with me today and address this important issue and what you've seen working and the efforts that you've taken to take steps to solve this. Thank you so much.
- [17:31]
B
Great. Thanks for having me on the podcast, Grace. Great to chat with you.
- [17:34]
A
Absolutely.