Physicians still waiting for CMS clarity on anti-workplace violence signs

Ever wonder why airport security has signs that discourage violence against its workers, but some emergency departments don’t?

Healthcare leaders say that’s because they aren’t sure how to phrase the signs without getting in trouble with regulators.

“The most basic element of prevention is often out of reach—that is, signage that sets expectations for respectful behavior and emphasizes that violence toward staff, patients, or visitors is unacceptable and could have consequences,” reads a Jan. 20 letter from medical societies and trade groups to the Centers for Medicare and Medicaid Services (CMS).

Forty-eight states have laws that outline penalties for violence against healthcare workers, ranging from fines to felony charges, as of June 2024.

The letter asked for clear written guidance with guardrails and examples of appropriate signage. As of publication the groups haven’t heard back from CMS, Laura Wooster, one of the letter’s leaders and the associate executive director of advocacy and practice affairs at medical society the American College of Emergency Physicians (ACEP), told Healthcare Brew over email.

Backing up. Violence against healthcare workers is a huge issue. A January 2024 survey of emergency physicians by ACEP found 91% reported they had been threatened or attacked in the workplace in the past year. A 2023 survey from union National Nurses United (NNU) found 82% of nurses had been assaulted or threatened, and nearly half said this increased over the last year.

At the same time, prevention efforts need to be balanced so they don’t stop people in crisis from getting care.

Though limited, research suggests efforts to reduce violence need to be multifaceted, targeting staff, patients, and the emergency department environment. A 2017 randomized controlled trial found that giving unit-level data to supervisors and requiring them to develop a unit-specific action plan reduced violent events from patients and patient visitors.

One part of that, leaders argue, is signage. They say they’ve asked CMS for guidance on signage before, and the agency has told them it allows signs on a case-by-case basis as long as the content doesn’t violate the Emergency Medical Treatment and Labor Act (EMTALA)—a 1986 law that guarantees public access to emergency services—per the groups’ letter.

“Compliance is assessed based on whether the content, tone, or placement of the sign could reasonably be interpreted as discouraging individuals from seeking or remaining for emergency care or suggesting that treatment may be denied or delayed,” a CMS spokesperson told Healthcare Brew.

But hospital leaders say they need specific examples of what they can and can’t write because federal surveyors have questioned signs before, saying they may deter patients from seeking or remaining for emergency care.

“Despite being asked for clarification, CMS declined to provide further explanation or overarching guidance, and said instead that EMTALA violations are considered on a case-by-case basis,” Wooster said.

It’s “essential” to increase protections for emergency healthcare staff, Jennifer Casaletto, a doctor and ACEP board member, said in a statement to us.

“No one should come to work expecting to be threatened or harmed while trying to save lives,” Casaletto said.

The big picture. It’s unclear how much of a difference hanging a sign makes. None of the groups from the letter gave us a specific example of a CMS citation for this issue when we contacted them.

Meanwhile, the state of Louisiana requires hospitals to hang a sign reminding patients that violence has consequences. CMS surveyors actually have cited multiple hospitals in the state for not hanging up signs, per CMS data.

Besides, reducing violent attacks on healthcare workers will require way more than just signs, Mary Turner, a registered nurse and a president of the NNU, told us via email.

“‘No tolerance’ signs don’t come close to being the solution that patients and nurses need,” Turner said.

Accrediting agency the Joint Commission asks hospitals to take steps such as creating a workplace violence prevention program and providing training and education, per Ken Grubbs, the agency’s chief nurse executive and EVP of accreditation and certification operations.

NNU also supports bills like the Workplace Violence Prevention for Health Care and Social Service Workers Act, which would bring requirements to the federal level.