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Illustration by Iker Ayestaran

Inoculating Against Violence

​Sixty percent of all documented workplace violence occurs in a healthcare setting, according to the American Nursing Association, which also suggests that the actual percentage is probably much higher. Violence has become an epidemic in healthcare, and I have seen it firsthand in my role at the Athens Regional Medical Center in Athens, Georgia.

Athens Regional offers a full spectrum of medical services to 17 surrounding counties, and its level-2 trauma center treats more than 70,000 patients annually. Despite its small size, Athens is an action-packed city that boasts a vibrant music and arts scene, robust manufacturing, and the University of Georgia, which swells the county population to more than 150,000 when in session.

The Georgia Bureau of Investigation’s most recent report shows that the Athens metropolitan area has an average crime rate for the state, coming in eighth out of 15 metro areas. However, Athens-Clarke County reports that 33.5 percent of its population lives below the poverty level—more than twice the national average. 

Although the Athens Regional facility sits between two historic Athens districts that have some of the lowest crime rates in the county, the medical center still deals with an operational environment that is increasingly prone to acts of violence against its staff. 

These environmental issues along with the national trends of violence in healthcare have led the security management team at Athens Regional to take steps beyond the “stand your post” and “roving patrol” security models towards a more dynamic approach to healthcare security. 

This move spawned the development of three essential tools designed to com­bat rising violence and shift the strategic paradigm from reactive security strategies to proactive security strategies: putting time into effective internal investigations, conducting comprehensive threat assessments, and crunching the data to identify criminal trends as they occur.​

Internal Investigations

The reports that security officers write and submit are a gold mine of information for organizations. Security managers can use incident reports for internal trending and criminal activity tracking. They can also be used for threat assessment and analysis, and for instructing staff how to serve customers.

A thorough initial incident investigation is key to both successful reporting and successful customer service. Every report filed constitutes an initial investigation of the incident. Once the scene is safe, the responding security officer should identify and interview the complainant, subjects, and witnesses. 

At Athens, the security officers make notes of all times, dates, conditions, and other details that may prove important for follow-up investigations. Officers are trained to collect every possible piece of information available to create the most accurate picture of the incident for security, administration, and investigations.

Additional information may often come after an incident has occurred and the initial report has been filed. It is important to establish a supplemental report process so security officers have a mechanism to add additional information to their incident reports. This ensures that every report is as complete as possible, and that officers are not limited in their ability to gather information about an incident.

Once an initial report is filed and supplemental information has been gathered, it’s crucial to conduct a follow-up investigation. Handing the report over to a trained investigator allows the organization to look more deeply into an incident, gather evidence, evaluate threats, and conduct complete customer service. 

Investigators have the ability to conduct follow-up interviews, collect photographic and video evidence, and liaise with local law enforcement, if necessary. Investigators are also able to connect the dots across the various departments within the organization.

For example, at Athens Regional, officers take reports from patients who have lost property. These reports are handed off to an investigator for follow-up. In most cases, the investigator will call the complainant and discover that the individual found the property at home, closing the case.

Recently, however, investigators be­gan noticing a trend in lost property cases where items went missing from the same floor and were not found. Security began to suspect that an employee was taking these items, and security decided to investigate more intently, gathering lists of employees working on that floor, conducting interviews, and suggesting an increase in security officer patrols on the floor.

Within a month, Athens Regional went from 30 to zero lost property reports on the floor in question. While security was unable to identify the thief, the unwanted activity stopped, and suspects were identified to monitor for future thefts. 

Athens Regional would never have seen this trend without follow-up investigations carried out by trained investigators. Also, the follow-ups allowed security to take the first step in predictive patrolling, allowing investigators—who have a bird’s eye view of internal incidents within organizations—to aid security in targeting patrolling efforts to mitigate potential criminal trends, like recurring thefts.

Another key benefit of follow-up investigations is the ability to identify risk and threat potential in an incident. Different security officers working different shifts may not realize they are continually dealing with the same threatening patient, or that the patient’s behavior is escalating with every visit. A follow-up investigation allows the organization to see these patterns more clearly and to determine the level of threat involved.

Additionally, follow-up investigations on suspicious person reports, theft reports, or lost property reports may expose a risk to the organization that was previously missed, and allow the organization the opportunity to mitigate it.​

Threat Assessment

Healthcare professionals are all too familiar with patients or visitors who repeatedly attack staff members. Reporting on these individuals is the key to successful threat analysis. Security officers who interact with these subjects can file incident reports based on the situation, and from that baseline the organization can begin tracking all the interactions the individual has within the facility. 

A relevant threat analysis combines internal reports with external criminal background checks to create a more comprehensive picture for security. Many organizations employ outside agencies to conduct external background investigations. However, this strategy can become expensive.

Instead, for those who want to keep costs at a minimum—like Athens Regional—effective background investigations can include a simple Internet search using background report sites like PeopleSmart or Checkmate, open source sites from a department of cor­rections or local law enforcement agency, or other Internet sites, like Athens Regional has been successfully using this approach to conduct background investigations.

Background checks, no matter what method is used, fill in more information about the subject and give security a greater understanding of what kind of threat the individual presents. For instance, Athens Regional noticed that it had recurring internal reports on an aggressive female visitor. When a background check was conducted, security realized she had a criminal history that included assault. She may not have been violent in the facility—only disruptive and threatening—but security was now aware that she had been violent in the past, elevating the potential threat.

Once recurring reports are gathered, background checks completed, and a threat level assigned (see box for more on threat levels), the work has only just begun. Continued tracking now becomes paramount to maintaining a successful watch over this known threat. Athens Regional must continue to monitor the incident reporting from security staff and the subject’s involvement with local law enforcement to maintain an active understanding of the threat the subject presents.

Lastly, there must be a plan to mitigate the threat. Establishing an interdisciplinary threat team to look at and create plans to address threatening subjects who present themselves for medical treatment or accompany patients is a great way to get buy-in from clinical staff, as well as from administrators. 

At Athens Regional, security chairs an interdisciplinary threat team comprising representatives from public safety, risk management, the emergency department, medical, and administration. This team discusses recurring personalities that present a threat and sets the parameters under which care will be provided, ensuring that the patient’s rights are protected and that the hospital complies with federal laws, such as the Emergency Medical Treatment and Labor Act. This group has been successful in establishing a plan to mitigate any threats presented.

For example, earlier this year the emergency department at Athens Regional filed a report on a man for disorderly conduct. Two weeks later, an information booth attendant filed another report involving the same man. The same man harassed a social worker a week later. These recurring reports triggered a more comprehensive threat analysis of the individual.

The threat analysis was then presented to the interdisciplinary threat team. For this subject, the team agreed to assign a high-level threat rating. The team determined that the subject would only be seen in the emergency department, and that registration staff would summon security officers if they spotted him.

The officers would then respond immediately with multiple personnel, and at least two would stay with the subject throughout treatment. The man would only be treated in a room equipped with video and audio monitoring. He would also be triaged immediately and evaluated by medical staff as quickly as possible.

The team also decided that if the physician identified no medical issues, the man would be discharged and escorted off the property by security officers. If he issued threats or if other problems occurred during the visit, security would then contact local law enforcement and file a report. Athens Regional would then file charges based on the issues presented by the man during his visit.​

Criminal Activity Trending

Security managers must have a historical understanding of what crimes have occurred at their facility and in the surrounding area. This is a critical first step in the development of external intelligence, as well as in trending and predicting future criminal activity.

A simple way that Athens is doing this is by learning about the crimes that have occurred in our area over time. This is done by asking basic questions, such as how many robberies have occurred over the last five years? In which months do most robberies occur? Is that pattern static over the full five years? Does a pattern develop in geographic movement of robberies over time? 

Security managers can obtain this information by using open source reporting by local law enforcement agencies. Access to sites like, local law enforcement media releases, and one-on-one liaising with law enforcement can provide a great deal of information about the criminal trends in the area.

Athens Regional’s local police department has a Crime Analysis Division with officers dedicated to the analysis of criminal trends in the city. Liaising with these officers has proven invaluable to the organization as Athens conducts assessments of potential new building sites for future facilities.

This information can then be put together to map crimes and document trends, allowing security managers to take proactive steps to prevent crime. Predicting criminal activity can be difficult, but once security understands what crime is occurring, when it’s occurring, and where it’s occurring, reasonable estimations of future criminal activity can be developed. 

For example, Athens Regional recently focused on robberies in the neighborhood. Studying the robberies over time, the hospital learned that an average of 2.6 robberies occurred per month within a 3-mile radius of the facility over the previous several years. Since February 2015, robberies have spiked from the average of 2.6 per month to an average of 12 per month in February, March, and April.

This obvious trend points to a new and aggressive offender operating right at the hospital’s doorstep. To study the trend spatially, security managers plotted each robbery on a map and watched how those robberies moved over time—witnessing a pattern of robberies moving east and north, and coalescing in a more concentrated pattern just miles from the facility.

From this research, the hospital reasonably predicted that the risk of robbery occurring in or around that geographic cluster was significantly elevated, and it adjusted strategies to help mitigate this threat. Having this knowledge allows Athens Regional to provide security for staff and visitors from a proactive standpoint by adjusting patrols, installing more targeted physical barriers, and, most importantly, by educating staff on the threat and giving them the knowledge they need to defeat it. 

One of the most successful ways Athens did this was by issuing a Critical Incident Watch (CIW) to all staff members. This document serves the purpose of a Be On the Look Out (BOLO), but is specific to a circumstance or situation rather than a person or a vehicle. 

The CIW went out to all staff, and was published on Athens’ internal Web page. It offered information about the incident and what steps could be taken to prevent such robberies. It also reminded staff to report suspicious activity.

Since the implementation of these strategies, the number of robberies has dropped significantly, but more importantly, the customers Athens Regional serves have praised the proactive security approach. The assurance of their personal safety was a critical success for the security program. 

The challenge faced by all security managers in the healthcare environment is learning to include data-driven strategies in their ever-expanding skill sets to see threats in real time and take proactive steps to mitigate those threats. Using these simple strategies, security managers can begin to meet this challenge to provide the kind of information needed for security officers to operate effectively and for their organization’s staff and patients to feel secure.


Charles Hodges is a public safety training coordinator and shift supervisor for the Athens Regional Health System in Athens, Georgia. He is a certified healthcare security supervisor and a veteran of the U.S. Army, earning two commendations from the FBI and a Humanitarian Service Medal for operational support after Hurricane Katrina. He is a member of both ASIS International and the International Association for Healthcare Security and Safety.