The workers’ compensation industry is focused on responding to injuries. What if the most important work comp claim is the one we prevent from ever happening?
That question was in my head while moderating the National Comp session “Before the Breaking Point: An Integrated Framework for Workplace Violence Prevention and Response” on September 29. Of all the great content included in the agenda, our session was the only one devoted specifically to workplace violence.
At first glance, that subject might seem a little out of place at a work comp conference. It is reasonable to assume that workplace violence is a safety, security, HR, or law enforcement issue. And it certainly is all of those.
Except when someone gets hurt and becomes a workers’ compensation issue. Maybe workers’ compensation needs to start thinking a little further upstream.
That premise launched an excellent discussion with Ari Stowell (Corporate Director of Workforce Health & Safety at HCA Healthcare), and Dan Hanlon (Director of Training & National Account Development at The Noble Group). Dr. Ann Hawkins (Chief Innovation & Marketing Officer at Health Karma Inc.), who helped plan the session, had a schedule conflict and couldn’t join us.
Dan spent 30 years in law enforcement before bringing that experience into workplace violence prevention. Based on his experience, serious incidents usually have a history. As Dr. Hawkins put it on one of our slides, “Workplace violence doesn’t begin with violence. It begins with warning signs.” Dan described those signs as increasing hostility, intimidation, threatening language, and talk of retaliation or harm, along with changes in behavior or attendance and substance abuse.
Dan’s concern wasn’t whether somebody noticed those warning signs. It was what happened next, which he distilled into four questions:
- What did we know?
- When did we know it?
- What did we do?
- What did we document?
Those are certainly important questions after something terrible happens. But they are much more valuable before they do. Dan mentioned the increasingly high cost of negligence and the evolving regulations around prevention and response that involve all four of those questions.
Unfortunately, the numbers are moving in the wrong direction. We discussed how COVID was an inflection point for mental health and wellness. According to NCCI, nonfatal workplace assaults rose at an annualized rate of 5.3% from 2011 through 2022. The Bureau of Labor Statistics counted 470 workplace homicides in 2024, up from 458 in 2023.
Dan said violence creates consequences beyond the person who is physically attacked. Coworkers witness it. Teams experience it. People may become afraid to return to the same environment. Psychological injuries can emerge alongside physical ones. Turnover, absenteeism, and morale can all be affected.
To underscore his point, Dan described the November 2022 incident in Chesapeake, Virginia, where a supervisor opened fire in the employee break room and killed six coworkers. The subsequent lawsuits allege the employer knew about the shooter’s prior threatening behavior, that employees had reported him, and that nothing was done. Dan described a survivor who was seated next to a coworker who was shot in the head. He did not sugarcoat what that means for a claim. That’s not a typical recovery timeline. It’s a claim that may last a lifetime.
Run that case through the four questions, and the answers are hard to read.
Healthcare makes this particularly visible.
Ari told us that HCA Healthcare has seen a dramatic increase in workplace violence since the pandemic. HCA employs approximately 320,000 people across a system of roughly 190 hospitals and thousands of other care locations. Most people do not manage workplace safety at anything remotely approaching that scale. But what HCA learned while trying to solve the problem at that scale can apply to every employer.
Ari pointed out that, by her count, only 22 states currently have laws addressing workplace violence in healthcare. A review by Epstein Becker Green counted at least 20 as of March, so the list is growing fast. Dan pointed out that the mandates aren’t just for healthcare. California’s law reaches most employers, and New York has extended similar requirements to retail. In Dan’s opinion, California currently has the most stringent mandates and can be a good starting point for others. Whether or not your state requires a prevention program, the negligence lawsuits Dan described don’t wait for a mandate.
Ari identified five challenges: standardization, visibility, accountability, culture, and ownership. When she asked which mattered most, the room guessed it: culture.
Healthcare has historically tolerated a certain amount of violence as part of the job. When a patient is sick, confused, medicated, frightened, or elderly, it can be part of the culture that a behavioral health crisis is “understandable.” While those circumstances may explain behavior, they do not make an employee’s injury acceptable.
That distinction matters far beyond healthcare. Every organization has things they simply learn to tolerate:
- “That’s just how he is”
- “She was angry”
- “Nothing actually happened”
- “We don’t want to overreact”
Until something bad happens and “nobody saw it coming.”
Interestingly, Ari said that when HCA made reporting easier and more consistent, its reported numbers initially went up. That wasn’t failure. It was visibility. You cannot manage what people are afraid, unwilling, or unable to tell you about.
HCA eventually organized its approach around three pillars: people, process and technology:
- People means leadership involvement, accountability, and culture
- Process means standardized reporting, training, follow-up, and clear expectations
- Technology means giving people practical ways to report problems, communicate quickly, and get help when something happens
At HCA, that includes executive oversight and workplace violence committees at individual facilities. It includes centralized incident reporting that allows employees to self-report and automatically alerts the appropriate team. It’s even piloting wearable duress buttons that employees can activate when they feel unsafe or threatened. HCA chose a top-down approach in which leadership is financially incentivized to plan, document, and enact both proactive safety steps and quick response. Each year, facilities earn credits or are charged debits based on how their program is graded. Regardless of an organization’s size or industry, a whole-of-enterprise system will uncover and address blind spots while reducing resistance to engaging with red flags early. In the famous words of Barney Fife, “nip it in the bud.”
Based on the insights from Dan and Ari, I noted five intentional things that every employer can do:
- Decide who owns workplace violence and make sure the answer is “all of us.” Security cannot solve this alone. Neither can HR, risk management, workers’ compensation, or safety. Someone needs responsibility for coordinating the program, but information must move across all organizational silos. At HCA, workplace violence prevention deliberately brings together leadership, legal, HR, employee health, behavioral health, security, patient safety, and other disciplines. While smaller organizations may have fewer people and departments, silos still exist. On this subject, those communication and coordination barriers must be removed.
- Give employees one obvious way to report concerns. If an employee sees troubling behavior, do they know where and when to report it? As importantly, do they have confidence that something will happen when they do? Reporting needs to be easy, understood, and trusted. Don’t measure success simply by fewer reports because, as Ari pointed out, sometimes more reporting means your reformed culture is working. As Dan recommended, offer a confidential or anonymous option for people who fear retaliation.
- Train people to recognize what happens before violence. Don’t limit training to what employees should do once an attack begins. Teach supervisors and employees to recognize increasing hostility, intimidation, fixation on grievances, behavioral changes, and threatening language. Then teach them what to do with the red flags that are identified. You don’t want to be the one who “never saw it coming.”
- Create a repeatable process for acting on information. A report without follow-up is just documentation, and the people who report it ultimately know if it’s a useful or useless exercise. Establish who reviews concerns, how risk is escalated, what corrective action is available, and how the response is documented. Periodically test whether the process works. This is very similar to an organization’s disaster recovery plan that looks good on paper but doesn’t work when a disaster happens.
- Learn from every incident, including the ones that almost happened. Don’t close the file when the immediate danger ends. Ask what was known beforehand. What worked? What did not work? What communication succeeded or failed? What should change? The goal isn’t simply to recover from an event. It is to make the organization stronger because of what it learned.
To quote one of the most provocative slides: “Workers’ compensation isn’t only about paying claims after harm occurs. It’s about reducing frequency, severity, duration, and exposure.”
We talk constantly about injury prevention, ergonomics, slips and falls, fleet safety, safe lifting, and return to work programs. After preparing for and delivering this session, I’d argue that workplace violence belongs in that same conversation. Perhaps the artificial line between prevention and workers’ compensation deserves to disappear.
So, ask yourself: If someone at your company started showing these warning signs tomorrow, would anyone notice? Would anyone report it? Would anything happen if they did?
If your honest answer to any of those is “I don’t know,” that’s your first finding. Someone will eventually ask Dan’s four questions. The only choice is whether it happens before the incident or after.
