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Safety Awareness For Substance Abuse Professionals and Facilities 20-740536 2-Hours Back to Course Index




Upon successful completion of this course, the learner will be able to:

  • Discuss and handle onsite threats.
  • Be able to identify who to call in an emergency.
  • Understand how to keep equipment working properly.
  • Be able to handle complaints and grievances by staff and clients.
  • Discuss performance improvement


What will I do?  

With events such as terror, storm destruction, and wildfires being a real possibility, the importance of educating all healthcare providers on safety is a priority.  Preparedness is a critical competency that is needed by all members of the health care team.


The right message at the right time can save lives.


Mental health and recovery facilities can be dangerous places. From 2017 to 2019, health care institutions reported a 32 percent increase in violent crime, with more than 13,000 incidents mostly directed at employees. Assaults linked to gangs, drug dealing, and homelessness spill in from the streets, domestic disputes involving hospital personnel play out at work, and disruptive clients lash out. The added component that comes with drug and alcohol use and mental instability only escalate the potential. Facilities must have strong policies to react quickly to threats to protect employees and clients.

Effective communication with a well-understood, planned response can make the difference between life and death.

Depending on the size and type of setting, examples of events that a facility might need to be prepared for include:   

  • Patient surge, Patient triage, Patient Identification, Patient tracking
  • Response Guides (Codes plus Dept. specific)
  • Hospital Incident Command in the event of an emergency
  • Fatality Management
  • Volunteer Management
  • Communications
  • Utilities (generators, water, etc..)
  • Safety & Security (traffic, access control, etc..)

A few more general safety areas include ensuring that personal protective equipment is available and the staff is trained to use them properly.  These should be maintained so that they are ready when needed.  Also, floor surfaces should be clean, clean, and dry.  Postings regarding how to report incidents and workplace tolerance can be helpful. 

Safety Team:  An established team with scheduled, regular meetings should be ongoing, if appropriate.  Minutes should be taken at each meeting.  Experience has shown that items talked about and left open and not talked about again without closure will get facilities into trouble.


Security includes the processes implemented to effectively manage the security of everyone within the facility. This could include:

  • Access control
  • Panic/Intrusion Alarms
  • Infant Security
  • Visitor access (after-hours)
  • Cameras
  • Vehicle security
  • Call boxes
  • Workplace Violence identification/response training
  • Security audit/Risk assessment
  • Policy enforcement-weapons, zero tolerance, background checks upon hire
  • Establishing protocols for a buddy system
  • HIPPA and EMTALA reviews
  • VIP/Media policy
  • Posting such as Property Subject To Search By Security and No Photography On-Premises

The Security Management Plan outlines several measures taken by the organization to ensure patient, employee, and visitor safety.  These measures are facility-specific—the following offer general guidelines.  Please request further information from your specific facility.

  • All employees should display their identification badges, if provided,  while on property.
  • Vendors, visitors, and outsourced service providers should sign in at the Reception Desk upon arrival and sign out when they leave.
  • NO weapons of any sort should be allowed on the property.
  • When making a 911 Emergency Call, the specific address and exact location should be given.  

Security Measures

Various security measures exist to increase overall safety and security within the buildings and the surrounding outdoor environment.

Some of these include:

  • Exterior lighting
  • Identification of ‘high-risk’ areas requiring additional security (medical record areas, medication rooms, business office)
  • Security rounds
  • Visitor sign-in and identification
  • Surveillance cameras
  • Employee identification (picture ID badges)
  • Management of access to keys and/or door code locks, etc.


Workplace Violence

The workplace should be free from violence or threats of violence. While we can’t predict when violence will occur, there are some warning signs that may help to recognize the potential for violence in patients and co-workers or others coming into the organization.

Personal Factors:

  • Chronic or acute mental illness
  • History of violent behavior
  • Drug or alcohol problems
  • Medical condition or medication side-effects
  • Recent divorce or separation

Take Precautions

Think Prevention:

Violence can often be avoided if necessary precautions are taken. When dealing with patients and visitors:

  • Wear clothing such as low-heeled shoes to reduce the risk of injury
  • Avoid wearing jewelry to work.
  • Keep keys and pens, which may be used as weapons, out of sight.
  • Report all threats to your supervisor
  • Use the “buddy” system anytime you think that your personal safety may be at stake.

Defuse the Situation:

It is important that staff know how to defuse a potentially violent situation.  

  • Back off; give the person plenty of space.
  • Speak in a calm voice
  • Work to build trust
  • Let the person talk about why they are upset.
  • Listen carefully
  • Help define the problem by asking for examples of what the person means.
  • Explore solutions by asking open-ended questions
  • Provide clear, responsive feedback

It is a best practice for every organization to adopt a “zero tolerance” policy for workplace violence.  Any employee, regardless of position in the organization, should be disciplined up to and including termination for any violation of the workplace violence policy.


  1. Violent acts, such as hitting, shoving, or stabbing
  2. Possession of weapons on the property, such as a bomb or gun
  3. Verbal or nonverbal threats, such as “I’ll take care of you” or shaking fists or waving a knife
  4. Intentional damage to property, such as slamming doors, hitting walls, or breaking equipment

Property – Employees should have NO expectation of privacy for organizational property.

This includes:

  • Offices
  • Desks
  • Lockers
  • Computers
  • Phones
  • E-mail


Hazardous Materials and Waste

Hazardous materials are any items that may be considered infectious or any chemical with properties that may be flammable, combustible, damaging to skin or organs, or producing dangerous fumes.

Managing hazardous materials and waste at a facility is an important area.  These can include items such as:

  • Infectious (biohazardous)
  • Radiologic
  • Hazardous (flammable, corrosive, toxic, reactive)
  • Pharmaceuticals

The areas of concern include:

  • Permitting/Licensing
  • Disposal
  • Surveying atmospheres/Passive employee monitoring
  • MRI safety
  • Security of compressed gas
  • Annual training
  • After-hours emergency response
  • EPA notifications
  • Pharmaceutical waste management
  • Monitoring- training/competencies
  • Hazcom/DOT Training
  • Risk Assessments

Hazard Communication (Chemical Safety)

A hazard communication program is designed to provide pertinent information to employees working with or around hazardous chemicals. There are three components to the hazard communication program:

  • Labels / Storage
  • Material Safety Data Sheets (MSDSs)
  • Training


The first component deals with label requirements. All chemicals in use must be properly labeled and stored in a safe area. No chemicals are to be stored under sinks.

Material Safety Data Sheets (MSDSs)

The second component of hazard communication involves MSDSs. An MSDS is a document provided by the manufacturer, importer, or distributor of the hazardous chemical(s). It provides information on the hazards associated with hazardous chemicals and recommendations for safe use, handling, and disposal. The MSDSs must be available within the work area.

The MSDS is divided into sections. Each section is dedicated to a specific topic (i.e., Reactivity, Fire & Explosion Data, Health Hazards, etc.) Some of the sections are listed below:

  • Name of Chemical
  • Manufacturer
  • Chemical Components
  • Associated Hazards
  • Physical Characteristics
  • First Aid/Emergency Response
  • Spill and Leak Handling
  • Reactivity
  • Disposal Practices
  • Personal Protective Equipment

It is also important to know the hazards (symptoms of overexposure) of the chemicals in the work area in order to work safely with the chemical(s) or to make determinations regarding overexposure. This information is also available on the MSDS.


All staff should be regularly trained in hazard communication.


Fire Safety

An organization is responsible for protecting patients, visitors, and employees from the potential adverse effects resulting from fire emergencies. An extensive fire safety (life safety) policy, procedure, and education program should be developed to fulfill this responsibility.

A comprehensive fire safety plan is more than just periodic fire drills. It involves managing all aspects of fire safety, including items such as:

  • Fire Drills
  • Alarms
  • Preventive Maintenance
  • Fire response
  • Life Safety building safeguards (equipment, firewalls, fire doors, emergency lighting, etc..)
  • Interim Life Safety Measure Assessments
  • Life Safety Deficiencies

Recommendations in the area of fire safety include reviewing plans for improvement with the safety team, training kitchen staff in the use of fire extinguishers, protocols for gas valve shut-off devices, and fire drills for staff, including weekend staff, as the most important area, prevention.

Fire Prevention

The most important part of fire safety is prevention. The following are some guidelines or tips on how to prevent fires.

  • Never overload electrical circuits. Use heavy-duty surge protectors with in-line circuit breakers in areas where multiple receptacles are needed.
  • Never leave open flames unattended.
  • Store flammable/combustible materials in appropriate containers and away from heat and ignition sources.
  • Dispose of trash (paper, cardboard, and other combustible materials) promptly. Maintain good housekeeping.
  • All space heaters are to be Underwriter’s Laboratory (UL) listed and equipped with a tip-over cut-off switch.

Employees and visitors should observe a no smoking policy within the organization (no smoking indoors). Smoking can be permitted in designated areas. No smoking should be permitted near building entrances /exits. Compliance with the smoking policy should be continually monitored, and strategies developed to address non-compliance.

The following guidelines can be established for personal safety during a fire emergency.

  • Keep fire exits and stairwells free from any obstruction.
  • Identify the primary and secondary evacuation routes and keep those routes unobstructed.
  • Understand the use and know location of fire extinguishers and fire alarm pull stations (if available).
  • All staff should participate in scheduled fire drills.

911 should be called in case of a fire.

A common code for fire safety is R-A-C-E.  The RACE acronym stands for:           

Remove anyone from immediate danger.

Sound the alarm with a manual pull station.

Confine    Close all doors and windows.

Extinguish/evacuate   Know locations and how to use fire extinguishers.                              

Staff should be continuously aware of those patients or peers needing assistance in the case of an emergency situation so that their evacuation can be made as quickly as possible when necessary.


Evacuation Procedures

It is also very important that employees understand their responsibilities and know all evacuation routes if an evacuation is necessary due to a fire emergency. Listed below are some of the key points to remember:

  • When patients are evacuated from their rooms, check to ensure that the room is vacant, then close the door.
  • Assist those requiring additional help to safely leave the building.
  • Do not use elevators if present during a fire emergency.
  • Use primary or secondary evacuation routes to vacate the premises.
  • Avoid stairwells; first, try to evacuate using connecting corridors.
  • Roll call is to be taken at the designated “safe” area to ensure all have safely been evacuated.

It is critical that all employees know how to respond in the event of a fire emergency.


Weapons On-Premises 

Florida Statute section 394.458 states that “except as authorized by law,” it is a third-degree felony for any person to bring, carry, possess, or transport a “firearm or another dangerous weapon” upon the grounds of any “hospital (or mental health facility) providing mental health services.” 

As a practical matter, almost every hospital and hospital emergency room provide mental health services.  This means that from a purely technical standpoint, the statute seems to prohibit firearms or weapons anywhere on its grounds. 

Most hospitals or facilities employ an overhead code system to alert staff to what situation is occurring. When the code is announced overhead, it alerts the staff in the event of a weapon (i.e., gun, knife, etc.) is on the premises and posing a potentially deadly threat to patients, employees, visitors, etc.

The following procedures are suggestions to be employed in the event of a threat posed by a weapon:

  1. Page Code (TBD) overhead clearly three (3) times with exact location.
  2. Call 911.
  3. Employees not in the immediate area of danger are to calmly evacuate everyone not involved in the situation from the building.
  4. Do not attempt to physically remove the weapon from the threatening party.
  5. Utilize verbal de-escalation techniques if appropriate.


If you are unclear on any of these, ask for clarification as an employee.


Bomb Threat 

A bomb threat requires specific activities to be followed to ensure the safety of all those in the building and on the premises. In addition to specific activities required by the person receiving the threat, evacuation of the building should take place. As with the weapon onsite, if a facility has an overhead code system, employees should be made aware of the code for a bomb threat.

If you receive a call/information about a bomb threat, listen carefully, and record answers to the following questions (use a Report Form if your facility has one readily available):            

  1. When is it going to explode?
  2. Where is it right now?
  3. What does it look like?
  4. What kind of a bomb is it?
  5. Why did you place it here?
  6. Time called:_________________
  7. Male or Female caller: M____   F____
  8. Adult or Child: Adult____   Child____
  9. Background noises:_____________________
  10. Other important notes__________________

Page the code overhead and begin following procedures:

  1. Call 911
  2. Begin a search of your immediate area for any “package or device” that does not belong there or appears suspicious.
  3. If such a “package or device” is found, DO NOT TOUCH OR MOVE IT.
  4. Safely evacuate the building and do not cause panic in patients or others.

For further information on the procedures for your facility, please speak to human resources or your supervisor. 



Active Shooter  

An active shooter is defined as “an individual actively engaged in threatening with a firearm, killing or attempting to kill people in a confined and populated area”; in many cases, there is no pattern or method to their selection of victims.

In order to preserve life and address the reality of an active shooter event, these guidelines have been established to guide a response to this event to maximize survivability.

Most importantly, quickly determine the most reasonable way to protect your own life. Speak to your supervisor about your facility’s specific response protocol.

The intent of most active shooters is to kill as many people as quickly as possible. Traditional law enforcement responses will include the concept of “surround and contain” in order to minimize the number of victims. In order to save lives, the law enforcement agency having jurisdiction will initiate an immediate response.

Upon discovery of an active shooter situation, as soon as possible and when safe to do so, notify law enforcement (911), and if your facility has an overhead code system, provide the announcement and location.

The phone call to 911 (from the area where they are safely concealed) should provide the following information:

  • Description of the suspect and possible location.
  • Number and types of weapons.
  • Suspect’s direction of travel.
  • Location and condition of any victims

Safety & Security Officers and/or the Administrator/Person in Charge should meet and guide law enforcement officers, if possible, and as appropriate.

The goal of law enforcement is to locate, isolate, and neutralize the shooter as quickly as possible to prevent additional deaths or injuries.

If there is an accessible escape path, attempt to evacuate the premises.                                   

Be sure to:

  • Have an escape route and plan in mind
  • Evacuate regardless of whether others agree to follow
  • Leave your belongings behind
  • Help others escape, if possible.
  • Prevent individuals from entering an area where the active shooter may be
  • Keep your hands visible.
  • Follow the instructions of any police officer.
  • Do not attempt to move wounded people.
  • Call 911 when you are safe.

If evacuation is not possible, find a place to hide.

  • Direct personnel into resident rooms or other adjacent rooms, close the door and attempt to barricade the door.

Your hiding place should:

  • Be out of the active shooter’s view.
  • Provide protection if shots are fired in your direction (i.e., locating into a resident bathroom and locking the door, stay as low to the floor as possible, and remain quiet and still)
  • Do not trap you or restrict your options for movement.

To prevent an active shooter from entering your hiding place:

  • Lock the door
  • Blockade the door with heavy furniture

If the active shooter is nearby:

  • Lock the door
  • Silence your cell phone and/or pager
  • Turn off any source of noise (i.e., radios, televisions)
  • Hide behind large items (i.e., cabinets, desks)
  • Remain quiet

If evacuation and hiding out are not possible:

  • Remain calm
  • Dial 911, if possible, to alert police to the active shooter’s location.
  • If you cannot speak, leave the line open and allow the dispatcher to listen.

An “all clear” code should be announced if possible when the situation has been addressed and law enforcement officials declare the scene safe.

The health and well-being of patients, residents, clients and employees are critical. As soon as possible, after law enforcement has relinquished Command and Control of the scene, the facility administrator and social worker will develop information strategies to address resident, employee, and family questions related to the event.

Initially, the site of a violent incident should be secured as a crime scene. After the authorities have completed their investigation and have released the scene, management will need to have the facility appropriately cleaned and sanitized.  

Cleanup for the safe removal of bio-hazardous substances, including bloodborne pathogens, must take place, yet must be sensitive, compassionate, and caring for those involved in the situation.

Effective coordination with the media and timely dissemination of information can help reduce media pressure on those who are the most vulnerable. Assistance with employee benefits and other administrative issues can reduce the burden on victims and families. An administrator should be designated as the Public Information Officer, who is authorized to speak to the media on behalf of the facility. 

All employees involved in the incident have to write an incident report, and the incident will be reported on IRAS as a Sentinel Event with DCF.


Natural Disasters

Natural disasters are large-scale geological or meteorological events that have the potential to cause loss of life or property. These types of disasters include:

  • Tornadoes and Severe Storms
  • Hurricanes and Tropical Storms
  • Floods
  • Wildfires
  • Earthquakes
  • Drought

Severe storms and floods are the most common types of natural disasters reported in the United States. These meteorological events are occasionally preceded by presidential “emergency declarations” requiring state and local planning prior to the event, such as evacuations and protection of public assets. Disaster Distress Helpline staff are available to speak to those who call or text before, during, and after a natural disaster.


Man-Made Disasters

Examples of man-made disasters include industrial accidents, shootings, acts of terrorism, and incidents of mass violence. As with natural disasters, these types of traumatic events may also cause loss of life and property. They may also prompt evacuations from certain areas and overwhelm behavioral health resources in the affected communities.

In the aftermath of the tragic loss of life that occurred on September 11, 2001, the feelings of loss of security and well-being—arguably the most crucial ingredients for leading a happy, healthy life—dramatically affected the citizens of the United States. Disaster Distress Helpline staff are also trained to respond to calls or texts related to these types of disasters.


Incidents of Mass Violence

Incidents of mass violence are human-caused tragedies that can impact whole communities and the country at large. These types of disasters, including shootings and acts of terrorism, often occur without warning and can happen anywhere, as shown by the Sandy Hook Elementary School tragedy of 2012 and September 11, 2001.

These violent acts typically target defenseless citizens with the intent to harm or kill. They can instill feelings of confusion, fear, and helplessness in survivors. Incidents of mass violence disturb our collective sense of order and safety and may even impact those with no personal.



Other Emergencies

There are also many situations other than natural disasters and man-made intentional threats that can lead to a disaster, such as chemical spills, radiological dispersion device events, explosions, and hazardous material incidents that can be accidental but cause serious disasters.





There are three basic groups of biological agents that could likely be used as weapons: bacteria, viruses, and toxins. Biological agents can be dispersed by spraying them into the air, person-to-person contact, infecting animals that carry the disease to humans, and contaminating food and water.

A biological attack may or may not be immediately obvious. In most cases, local health care workers will report a pattern of unusual illness, or there will be a wave of sick people seeking emergency medical attention. The public would be alerted through an emergency radio, TV broadcast, or some other signal used in the community.

In the event of a biological attack, public health officials may not immediately be able to provide information on what you should do. It will take time to determine exactly what the illness is, how it should be treated, and who is in danger.

During a bioterrorism event, wear a face mask to reduce inhaling or spreading germs. 

If you have been exposed to a biological agent, remove and bag your clothes and personal items. Follow official instructions for the disposal of contaminated items.  Wash with soap and water and put on clean clothes.  

The basic public health procedures and medical protocols for handling exposure to biological agents are the same as for any infectious disease. It is important for you to pay attention to official instructions via radio, television, and emergency alert systems.


Healthcare Facility Preparations

When disaster strikes, healthcare facilities, and their staff play an essential role in the response efforts. It is, therefore, vital to address emergency preparedness before help is needed. 

The design, preparation, and implementation of the emergency plan that includes all the procedures, strategies, organizational structures, potential hazards, personal protection equipment, and all the potential actions that can be completed in case there is an emergency is a foundation for a safe facility. The next important step is to provide training to all workers independently of the activity they do.  An emergency plan should incorporate:

  • Facility Risk Assessment – This multidisciplinary process should include representatives from all services involved in an emergency situation.   
  • Hazard Vulnerability Analysis – The Joint Commission on Accreditation of Healthcare Organizations requires member hospitals to complete an annual Hazard Vulnerability Analysis (HVA) to provide a foundation for emergency planning efforts.
  • Training – Everyone working at a healthcare facility needs to be adequately trained to react to disaster situations. 
  • Command and Coordination – Emergency situations are typically chaotic and confusing, but that doesn’t mean the response should match. Individual roles and responsibilities during the disaster should be clearly defined. 
  • Evacuation – When conditions are severe and force evacuation of the facility’s patients and staff, the safety of patients and the possibility of continuing their care rely entirely on a facility’s preparedness. Security and communication are vital in a successful evacuation. 

In consideration of the above areas, the comprehensive plan for dealing with emergency events should include:

  • Specific instructions to building occupants
  • Actions to be taken by facility management
  • First responder notification procedures
  • Evacuation procedures
  • Rescue and medical duties for those employees who are trained to perform them
  • Names or job titles of persons who can be contacted for further information or explanation of duties under the plan

As the emergency plan is created and put into place, other items to ensure are in place and well maintained include:

  • Portable fire extinguishers
  • Fire detection systems
  • Employee alarm systems
  • Fire prevention plans
  • Maintenance, safeguards, and operational features for exit routes like a sign
  • Automated External Defibrillators
  • First Aid kits
  • Personal protective equipment


Medical Equipment 

Processes to ensure patient care equipment’s effective, safe, and reliable operation should be established.  The areas of concern include:

  • Inventory
  • Preventive Maintenance
  • Physical risk
  • Inspections
  • Recalls
  • Safe Medical Device Act

A plan should detail the staff’s education on devices, what to do if a piece of medical equipment injures someone, an alert system or process for recalls, and how to handle equipment failures.


Grievance Systems

Emphasis on patient-centered care has increased, as have calls for transparency of patient satisfaction data. These trends in healthcare make seeking and responding to patient feedback increasingly important components of programs. Patients have the right to file complaints and grievances with the organization when they are unsatisfied with the treatment received, and healthcare organizations should have processes in place for handling both in a timely manner. In addition, tracking and trending of patient complaints and grievances may call attention to systems or individual performance problems and suggest quality improvement opportunities. For example, patient complaints are associated with both clinical complications and an increased risk of malpractice litigation.

Healthcare organizations must develop processes for addressing patient complaints and grievances to comply with regulations and accreditation standards, protect patients, and reduce liability. Complaints stem from minor issues that can typically be resolved by staff present at the time the concern is voiced, while grievances are more serious and generally require investigation into allegations regarding the quality of patient care. 

The Joint Commission and other accreditors’ complaint resolution standards also require that accredited facilities address and resolve complaints from patients and their families. 

The law also requires that these programs continually educate their staff on the importance of their specific grievance system. 

Each program should provide meaningful procedures for the timely hearing or resolution of grievances.  Clients should be told upon admission to a program how to initiate a grievance if it should become necessary.  The process should be covered in employee orientation.

Action Recommendations for Programs:

  • Design a process to capture and address all complaints and grievances.
  • Ensure the organization’s governing body or designated grievance committee’s involvement.
  • Implement policies, procedures, and processes to investigate and resolve patient complaints and grievances.
  • Educate all physicians and staff on grievance processes.
  • Train all staff to listen effectively and manage patient and family expectations.
  • Use the dedicated staff to solve small problems before they escalate.
  • Employ a proactive approach to customer service.
  • Empower front-line staff to act as the first line of defense against complaints.
  • Track complaints, grievances, and patient satisfaction surveys and implement improvement initiatives to address trends identified.
  • Verify that the grievance process is effective.

The process should provide a clear method for clients to report grievances.  Clients should be told:

  1. You have the right to use a facility’s internal grievance or complaint process any time you believe your rights have been violated.
  2. If you have been abused or neglected, you have the right to call the Florida Abuse Hotline at 1-800-962-2873.
  3. You also have the right to file a Writ of Habeas corpus or a Petition for Redress of Grievance to question:
    • being placed in a facility
    • being denied a right or privilege
  4. being treated in a way that does not follow a proper procedure
  5. You may ask staff members at a facility to give you a copy of a Writ and help you file it with the Clerk of the County Court.
  6. You also have the right to contact an attorney to request assistance.


The procedure for a client to make a complaint should follow these recommendations:

1. The Grievance Policy and Procedure should be explained and acknowledged by the resident or client upon admission to treatment.

2. Grievance Forms and Policy Poster should be provided and maintained in a conspicuous designated area at each treatment location.

3. The grievance should be investigated and addressed with the resident within 72 hours of the grievance submission date.

4. The resolution of the grievance should be documented and placed in the client or resident’s file and facility quality assurance grievance binder.

In the event that a client or resident’s grievance cannot be resolved internally, the client may contact:
The Florida Association for Recovery Residences (FARR) at 561-299-0405 or file a grievance through FARR by clicking the following link:
or contact the Abuse Hotline at 1-800-ABUSE

A facility should not subject residents who make complaints or have complaints submitted on their behalf to any reprisals, interruptions of care, or discriminatory or adverse treatment due to complaint filing.


Sometimes the complaint is internal and not from a client.  Employees may have occasional concerns or complaints that they need to share.  It is far better to have a procedure in place where issues can be resolved than to have these show up on glassdoor or other internet forums. 

Formal complaints by employees or individuals served and their designees should be submitted to a supervisor in writing and should receive a written response of the outcome of the complaint within a reasonable amount of time. The facility should exercise due diligence in investigating all internal and external complaints in an impartial and prudent manner. Secondary impartial consultants may be employed to assist with investigations as needed.

To report a complaint to The Joint Commission, use one of the following options:

E-mail: [email protected]

Fax: 630-792-5636

Mail: Office of Quality Monitoring
The Joint Commission

One Renaissance Boulevard
Oakbrook Terrace, Illinois 60181

The facility has the right to refuse care or dismiss a client from care if he or she is disruptive, uncooperative, belligerent or physically threatening to the physician, staff, other clients, or visitors.  Additionally, the facility has the right to refuse care or to dismiss a client from care in the event the designated responsible driver is incapacitated, disruptive, uncooperative, belligerent, or physically threatening to the staff, other clients, or any other party.


Performance Improvement 

Performance improvement best occurs at team, department, and organization levels.  It can range from a formal, rigid process conducted at timely intervals to a continuous,  real-time system that continuously looks at ways efficiency and care can be increased.  Every organization should develop strategic plans for constant improvement.  Medical errors can be reduced, treatment success can be improved, and employees can be happier and more efficient through root cause analysis.

Root cause analysis (RCA) is a systematic process for identifying “root causes” of problems or events and an approach for responding to them. RCA is based on the basic idea that effective management requires more than merely “putting out fires” for problems that develop but finding a way to prevent them.

  1. Step 1: Identify Possible Causal Factors. During the situation analysis, the project team set the vision, identified the problem, and collect data needed to better understand the current situation.
  2. Step 2: Identify the Root Cause. 
  3. Step 3: Identify Communication Challenges. 
  4. Step 4: Prioritize Communication Challenges.

Frequently programs create performance improvement committees to improve services.  They can look at feedback and incident reports and perform the necessary analysis.



How an organization plans for, responds to, and recovers from issues is critical to the safety of patients and employees.  Know your facilities, plans, and procedures.  Know how to contact a supervisor and emergency services.  

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