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Administrative (Non-Clinical) Policy
UWHC only (Hospital Administrative-entity wide) UWMF only (entity wide)
UWHC Departmental (indicate name) UWMF Departmental (indicate name)
UWHC and UWMF (shared)
Policy Title: Workplace Violence Planning & Prevention
Policy Number: 9.57
Effective Date: July 1, 2015
To minimize the frequency and severity of workplace violence at the University of Wisconsin Hospital
and Clinics (UWHC).
The UWHC has zero tolerance for workplace violence and is committed to establishing a safe workplace
and treatment facility for all employees, staff, patients, and visitors. The UWHC will fulfill this
commitment by ensuring proper reporting, documentation, and analysis of violent incidents in the
workplace. The UWHC will also assess physical security, provide appropriate workplace violence
training, and regularly reevaluate the UWHC's Workplace Violence Planning and Prevention and
Reporting and Discipline policies and programs.
A. Management Commitment and Employee Responsibilities
1. The Director of Security will direct and monitor implementation of this policy.
2. The Security and Human Resources Departments will assist with this policy's
a. Providing and monitoring training;
b. Conducting site assessments;
c. Conducting incident investigations; and
d. Reporting significant events to the Environment of Care Safety Committee.
3. All departmental managers and supervisors will facilitate the reporting of violent
incidents, as well as incidents indicating potential or imminent violence in accordance
with Hospital Administrative policy 4.22-Event Reporting and Hospital Administrative
policy 9.58-Workplace Violence Reporting, Investigation and Discipline.
4. All employees must report acts or threats of workplace violence to their supervisors,
managers, and/or Human Resources in accordance with Hospital Administrative policies
4.22 and 9.58.
B. Risk Analysis-The Director of Security will:
1. Review relevant data from multiple sources including: Quality, Safety &
Innovation (Patient Safety Net (PSN) reports), Human Resources (Violence/Threat
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Report forms), Worker's Compensation claims and illness/injury logs, security reports,
police records, or information from any other source related to workplace violence.
2. Identify patterns of individual violent or violence-inducing behavior (physical, verbal, or
non-verbal) that can be prevented through intervention, workplace adaptation, procedural
changes or employee training.
3. Periodically review information on workplace inspections and evaluate employee roles to
identify hazards and conditions, and operations and situations that could result in
violence or exacerbate violence.
4. Identify security-sensitive units, work sites, or positions.
1. All UWHC employees shall receive training on Active Shooter procedures and UWHC’s
workplace violence policy during New Employee Orientation (NEO). Workplace
violence topics may also be included in the annual Safety and Infection Control (SIC)
Training and additional courses, offered through Learning & Development, are available
2. UWHC employees in sensitive areas or positions may receive additional training about
workplace violence appropriate to their departments and/or positions. This training may
a. Restraint for violent patients.
b. Dealing with upset visitors to the facility.
c. Dealing with potentially violent employees.
d. Non-violent crisis intervention.
3. Workplace violence training will be documented and recorded in each employee's
personnel file or electronic record.
D. Effective Security and Process Improvement-Based on its analysis and all of the data the Director
of Security will:
1. Recommend training and security measures and procedures for the protection of
employees, staff, patients, and visitors from potential incidents of violence.
2. In developing these recommendations, the Director of Security will also consider
employee suggestions, and where appropriate, incorporate current State and Federal
Workplace Violence Prevention Guidelines.
Guidelines for Preventing Workplace Violence for Healthcare and Social Service Workers - OSHA
Publication 3148-04R (2015).
WI Admin. Code, Department of Commerce, Chapter SPS 332, Public Employee Safety & Health,
Hospital Administrative Policy 4.22-Event Reporting
Hospital Administrative Policy 9.58-Workplace Violence Reporting, Investigation and Discipline
Sr. Management Sponsor: VP, Facilities and Support Services; VP, Human Resources
Author: Director, Security
Review/Approval Committee(s): Environment of Care Safety Committee, Administrative Policy and
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President & CEO
Previous revision: 072012
Next revision: 072018