	Background

		OSHA and State Responsibilities for Worker Safety and Health

OSHA is responsible for protecting the safety and health of the nation’s  workers under the Occupational Safety and Health Act of 1970 (OSH  Act). OSHA Enforcement and Guidelines Related to Workplace Violence Prevention

OSHA does not require employers to have workplace violence prevention  programs; however, the agency issued voluntary guidelines in 1996 to  help employers establish them. Workers in Health Care Facilities Experience Higher Estimated Rates of Nonfatal Workplace Violence than Workers Overall, though the Full Extent of the Problem and Its Costs Are Unknown

		Federal Data Show That Workers in Health Care Facilities Have Higher Estimated Rates of Nonfatal Injury Due to Workplace Violence than Workers Overall

Workers in health care facilities experience substantially higher estimated  rates of nonfatal injury due to workplace violence compared to workers  overall, according to data from three federal data sets we reviewed (see  fig. II for more information on these  studies). According to NEISS-Work data from 2011,  hitting, kicking, and beating were the most common types of nonfatal  physical violence reported by workers in health care facilities. OSHA Increased Enforcement and Education Efforts, but Inspectors Face Challenges Taking Enforcement Actions and Following up on Hazard Alert Letters

		OSHA Increased Its Workplace Violence Inspections of Health Care Employers

OSHA increased its inspections of health care employers for workplace  violence from 11 in 2010 to 86 in 2014 (see fig. 5). From 1991 through October 2014, OSHA issued 18 general  duty clause citations to health care employers for failing to address  workplace violence. Staff from all 10 OSHA regional offices said it was challenging to cite  employers for violating the general duty clause when workplace violence  is identified as a hazard and staff from 4 OSHA regional offices said it  was challenging to develop these cases within the 6-month statutory time  frame required to develop a citation. When inspectors identify workplace violence hazards during an  inspection, but all the criteria for issuing a general duty clause citation are  not met and a specific standard does not apply, inspectors have the  option of issuing warning letters to employers, known as Hazard Alert  Letters (HAL). Without this additional information, inspectors may continue to  experience difficulties in addressing challenges they reported facing in  developing these citations. However, without a  policy requiring inspectors to follow-up on hazard alert letters, OSHA will  not know whether employers have taken steps to address the safety  hazards identified in these letters or whether a follow up inspection is  needed. However, OSHA has done little to assess the results of its  efforts. Without assessing the results of these efforts, OSHA is not in a  position to know whether the efforts are effective or if additional action,  such as development of a specific workplace violence prevention  standard, may be needed. Recommendations for Executive Action

To help reduce the risk of violence against health care workers, we  recommend that the Secretary of Labor direct the Assistant Secretary for  Occupational Safety and Health to take the following actions:
Provide additional information to assist inspectors in developing  general duty clause citations in cases involving workplace violence. To help determine whether current efforts are effective or if additional  action may be needed, such as development of a workplace violence  prevention standard for health care employers, the Secretary of Labor  should direct the Assistant Secretary for Occupational Safety and Health  to:
Develop and implement cost-effective ways to assess the results of  the agency’s efforts to address workplace violence. In its written comments, DOL’s Occupational Safety and Health  Administration (OSHA) said it agreed with all three of our  recommendations. Appendix I: Objectives, Scope, and Methodology

This report examines: (1) what is known about the degree to which  workplace violence occurs in health care facilities and its associated  costs, (2) steps OSHA has taken to protect health care workers from  workplace violence and assess the usefulness of its efforts, (3) how  selected states have addressed workplace violence in health care  facilities, and (4) research on the effectiveness of workplace violence  prevention programs in health care facilities. To address these objectives, we: analyzed federal data used by three federal agencies to estimate  workplace violence-related injuries and deaths in health care facilities; reviewed related studies identified in a literature review; interviewed federal officials, analyzed enforcement data, and  reviewed relevant federal laws, regulations, inspection procedures,  and guidelines; reviewed selected state workplace violence prevention laws from nine  selected states and visited four of the states where we interviewed  state officials, health care employers, and workers; and  interviewed researchers and others knowledgeable about workplace  violence prevention in health care facilities.
Why GAO Did This Study

Workplace violence is a serious concern for the approximately 15 million health care workers in the United States. OSHA is the federal agency responsible for protecting the safety and health of the nation's workers, although states may assume responsibility under an OSHA-approved plan. OSHA does not require employers to implement workplace violence prevention programs, but it provides voluntary guidelines and may cite employers for failing to provide a workplace free from recognized serious hazards. GAO was asked to review efforts by OSHA to address workplace violence in health care.
GAO examined the degree to which workplace violence occurs in health care facilities and OSHA's efforts to address such violence.
GAO analyzed federal data on workplace violence incidents, reviewed information from the nine states GAO identified with workplace violence prevention requirements for health care employers, conducted a literature review, and interviewed OSHA and state officials.

What GAO Found

According to data from three federal datasets GAO reviewed, workers in health care facilities experience substantially higher estimated rates of nonfatal injury due to workplace violence compared to workers overall. However, the full extent of the problem and its associated costs are unknown. For example, in 2013, the most recent year that data were available, private-sector health care workers in in-patient facilities, such as hospitals, experienced workplace violence-related injuries requiring days off from work at an estimated rate at least five times higher than the rate for private-sector workers overall, according to data from the Department of Labor (DOL). The number of nonfatal workplace violence cases in health care facilities ranged from an estimated 22,250 to 80,710 cases for 2011, the most recent year that data were available from all three federal datasets that GAO reviewed. The most common types of reported assaults were hitting, kicking, and beating. The full extent of the problem and associated costs is unknown, however, because according to related studies GAO reviewed, health care workers may not always report such incidents, and there is limited research on the issue, among other reasons.
DOL's Occupational Safety and Health Administration (OSHA) increased its education and enforcement efforts to help employers address workplace violence in health care facilities, but GAO identified three areas for improvement in accordance with federal internal control standards.
Provide inspectors additional information on developing citations . OSHA has not issued a standard that requires employers to implement workplace violence prevention programs, but the agency issued voluntary guidelines and may cite employers for hazards identified during inspections—including violence in health care facilities—under the general duty clause of the Occupational Safety and Health Act of 1970. OSHA increased its yearly workplace violence inspections of health care employers from 11 in 2010 to 86 in 2014. OSHA issued general duty clause citations in about 5 percent of workplace violence inspections of health care employers. However, OSHA regional office staff said developing support to address the criteria for these citations is challenging and staff from 5 of OSHA's 10 regions said additional information, such as specific examples of issues that have been cited, is needed. Without such additional information, inspectors may continue to experience difficulties in addressing the challenges they reported facing.
Follow up on hazard alert letters . When the criteria for a citation are not met, inspectors may issue warnings, known as hazard alert letters. However, employers are not required to take corrective action in response to them, and OSHA does not require inspectors to follow up to see if employers have taken corrective actions. As a result, OSHA does not know whether identified hazards have been addressed and hazards may persist.
Assess the results of its efforts to determine whether additional action, such as development of a standard, may be needed . OSHA has not fully assessed the results of its efforts to address workplace violence in health care facilities. Without assessing these results, OSHA will not be in a position to know whether its efforts are effective or if additional action may be needed to address this hazard.

What GAO Recommends

GAO recommends that OSHA provide additional information to assist inspectors in developing citations, develop a policy for following up on hazard alert letters concerning workplace violence hazards in health care facilities, and assess its current efforts. OSHA agreed with GAO's recommendations and stated that it would take action to address them.