Emergency departments in the post-9/11 world have found themselves becoming security posts, especially after campus lockdown hours. This new defense strategy in a world of weapons of mass destruction forces security staff and ED personnel to be experts in terrorism surveillance, mitigation and response.

The ED in this new environment requires health care security officers to function as a team with ED staff in heightened support of patient and staff safety, as well as quality care.

Core competencies

Most state relicensure surveys and hospitals accredited by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) must be able to demonstrate a competent workforce that supports efforts of safety within the environment of care.

Hospital security officers, like the clinical staff, must be ready to prove, explain and demonstrate such competencies. What might these include?

First, there are basic skills, such as knowing the codes and how one's department should respond. These support the hospital emergency incident command system (HEICS), whether formally activated with HEICS vests and command posts, or informally activated for day-to-day emergent responses.

There are also the common patient response activities, such as violence prevention or patient/visitor/staff threat
response. This usually entails de-escalation techniques and/or up to full takedown and restraint application.

Additionally, security officers are enhancing their knowledge and performance with customer service techniques because they often find themselves as one of the first contacts or responders when events escalate out of control.

Thus, the following competencies and knowledge indicators are required of hospital security officers:

• HEICS. Security officers should know their roles and responses pertaining to the organization and how HEICS interfaces with community and regional disaster plans.
• Meet and greet. Officers should know key strategies of successful customer service, such as welcoming and screening patients or visitors.
• Environment of care and safety. Officers should know their basic roles and responses for each internal or external code or emergency, such as fire, infant abduction or mass casualty influx.
• Restraints. Officers should be able to discuss the hospital's philosophy and policy on restraints, including alternatives to and the application of restraints.
• Crisis and workplace violence prevention. Officers should be trained in key strategies to prevent or respond to workplace violence situations by staff, patients or visitors.
• Handcuffs and forensics. Officers should be trained in the proper use of handcuffs through an accredited law enforcement class as well as hospital policy on the implementation of forensic situations (e.g., guarding a prisoner).
• Weapons/drugs surveillance and confiscation. Officers should be trained on search and seizure methods for possible weapons or drugs.
• Local and state criminal codes and standards. Security officers should be versed or able to access resources to validate local and state regulatory standards.

Additionally, in support of threats of terrorism, security officers must also be able to lock down buildings, tunnels and skybridges quickly or with the aid of the labor pool or automated systems, control traffic and crowds for mass casualty influx, and participate in decontamination procedures following the associated respiratory and hazard communication standards. (The use of personal protection equipment is compounded by typical barriers, such as limited sight, dexterity, hearing, communication and heat stress/fatigue.)

The security department is expected to be in the throes of any mass casualty influx resulting from a biological, radiological or chemical incident. When posed questions on this, officers must be able to respond clearly, accurately and assuredly. It is fine to refer to reference material, but the basic responses and initial setup and procedures should be second nature when time is of the essence.

The following are some heightened competencies that are required of security officers post 9/11:

• Emergent lockdown procedures. Security officers should be able to physically lock down perimeter doors, tunnels and skybridges to secure the hospital building.
• Respiratory etiquette, respiratory standards and fit testing. Officers should be trained on Centers for Disease Control and Prevention (CDC) standards for respiratory etiquette applied to patients and visitors (e.g., donning mask for uncontrolled cough) as well as fit tested according to Occupational Safety and Health Administration or state agency standards.
• Traffic and crowd control. Officers should be trained in how to safely redirect traffic and control crowds as it applies to emergency management procedures and potential decontamination scenes.
• Setting up decontamination and hot/warm/cold zones. Security officers should be skilled in setting up and maintaining zones in emergency management situations.
• Donning personal protective equipment (PPE). Officers should be trained to don and doff appropriate PPE based on exposure risks per incident.
• Facility security. Officers should know how to mitigate and respond to facility security issues.
• After-hours visitor access. Officers should know how to control access to the hospital after hours, when most perimeter access points have been locked down.
• Heightened awareness of potential terrorist activities. Officers should be able to proactively assess potential acts of terrorism by completing weapons of mass destruction/terrorism awareness training courses.

'Proving' the competencies

How will officers and managers need to prove such competencies? The JCAHO's new tracer methodology means staff directly or indirectly associated with 11 to15 commonly admitted patients traced throughout their normal course of care will be asked to speak to skills, knowledge and interdisciplinary plan of care. (These 11 to 15 patient tracers are chosen through a method called the "priority focus process.")

ED staff and security officers will be interviewed and asked to contribute to this discussion. While tracing patient care, JCAHO surveyors will likewise trace system issues, such as safety, infection control, emergency management, leadership and competencies. A wealth of information is gleaned at each stage during a tracer.

Documentation is provided on-site instead of at scheduled interview sessions. Staff and managers must be able to support the process at the patient's point of care, but keep in mind that the JCAHO survey process is driven to interact at the staff level. Managers and supervisors will be held aside while surveyors focus on "front-line" staff. Personnel on duty will be expected to explain and show competencies.

The best way to get officers comfortable with this approach is to get them used to explaining what they do, why they do it, and how they know how and what to do. The manager's role is to provide requested documentation of proof. This applies to all staff, including part-time and agency or contract services.

Building teamwork

In addition to these individual department efforts, what else can security and ED staff do to enhance security in the emergency department?

It is imperative that security officers and ED employees function on a first-name basis and easily recognize each other, sense when help is needed and build a rapport early to ease tensions during critical situations (or during a survey). This can be accomplished by having security participate in change of shift reports (i.e., both departments share key issues that occurred over the past 8 to 12 hours), physical and personal rounds performed by officers and ED staff versus having them sit behind a security or nursing post, actively soliciting input from both the security and ED staff sides regarding how emergency events unfolded, and seeking ideas and involvement proactively instead of when things escalate out of control.

Other team-building tactics might include holding joint staff meetings or in-services programs (e.g., security officers can give classes on verbal de-escalation and ED staff can educate on the pain response). In-house experts from education, safety, accreditation or quality improvement can also be utilized to educate, drill or facilitate team learning activities.

The following is a summary of these and other activities designed to encourage teamwork-based security:

• Developing familiarity. Officers and ED staff should be able to identify other key workers by name and face.
• Shift reports. Security and ED staff can participate in change of shift reports to update on key issues.
• Rounding versus desk duty. Security and ED staff should make direct appearances within departments.
• Debriefing sessions. Security and ED staff can conduct debriefing sessions after emergent incidents to capture improvement opportunities and address critical incident debriefing needs.
• Encouraging proactive safety efforts. Security and ED staff can look for ways to become more proactive in safety and security.
• Jointly participating in staff meetings. Employees from both sides may co-participate in existing or special meetings to build knowledge.
• Offering in-services programs. Security and ED staff can offer in-services programs to educate each other on their areas of expertise and interest.
• Joining hospital activities as a team. Security and ED staff can jointly participate in activities such as walks, United Way challenges and picnics.
• Asking the hospital's organizational development or education professionals to develop programs. Both groups may utilize internal expertise for specific courses on personality, team traits and collaboration techniques to enhance teamwork and relationships.
• Utilizing the hospital's safety officer to build and drill procedures. The safety officer can conduct drills and training specifically for security officers and ED staff.
• Utilizing the hospital's JCAHO coordinator to better understand standards and elements of performance. The regulatory coordinator can conduct mock surveys incorporating security officers and ED staff.
• Packaging goals in terms of quality improvement and getting credit for efforts gained. Security and ED staff leaders can present indicators according to the hospital's performance improvement methodology.
• Soliciting input from front-line staff. Leaders should ask workers in both departments for input on policies and procedures because the employees know what will work.
• Using data to support the case for staffing, surveillance or other safety ideas for both departments. For example, a security standby for suicide watch could lead to hiring a social worker in the ED; or theft data could lead to procuring a portion of a security officer to do internal investigations.
• Tracking employee satisfaction. Leaders can monitor satisfaction scores as an indicator of interdepartment team building.
• Encouraging security and ED staff to complete incident reports to capture internal data for quality improvement. Staff from both sides should understand use of forms and routing to communicate concerns for improvement.

Collaboration is key

Now more than ever, there are many reasons and opportunities for security officers and emergency department staff to work collaboratively.

Department silos must be broken down and, in turn, every department should join forces to work in a smooth, interdisciplinary manner--clinical, nonclinical and volunteers alike.

When this happens, staff and patients will both reap the rewards.

Marianne Klaas, R.N., is director of accreditation and safety at Swedish Medical Center, Seattle. This article is based on her presentation at last year's annual conference of the International Association for Healthcare Security and Safety. She can be reached via e-mail at marianne.klaas@swedish.org.