Emerging Issues in Health Care Management

Special Topics and Emerging Issues in Health Care Management

Sharon B. Buchbinder and Bobbie Kite

LEARNING OBJECTIVES

By the end of this chapter, the student will be able to:

■   Discuss the potential impact of re-emerging outbreaks, violence, substance use disorders, and disasters on a health care organization;
■   Analyze potential risks for violence in a health care organization;
■   Propose strategies for addressing violence in health care settings;
■   Examine the role of the health care manager in combatting re-emerging outbreaks;
■   Create a plan for an emergency plan for a health care organization; and,
■   Investigate key resources and data depositories for topics covered in this chapter.

Introduction

Health care managers stand at the intersection of social, public health, and medical issues, and must be able to deal with everyone who arrives at the emergency department (ED) with compassion and clarity. The purpose of this chapter is to bring some special topics and emerging issues, many of which are torn from today’s headlines, to your attention. You will be challenged to examine and analyze these sometimes volatile issues with thoughtful sensitivity and reflection. TRIGGER WARNING: This book chapter, or pages it links to, contains information about sexual assault and/or violence which may be triggering to survivors. Due to space constraints, this chapter will not delve into each one with the depth of preceding chapters. Instead, we will provide you with an overview to entice you to dig deeper into one or more of these areas which you find intriguing, unsettling, or provocative. In this chapter, we will address vaccine preventable diseases and re-emerging outbreaks, violence in health care settings, mental illness and substance use disorders and federal legislation, and emergency and disaster management. In addition, we will direct you to where you can find more resources on these topics.

Vaccine Preventable Diseases, Re-Emerging Outbreaks, and Deaths

Vaccines work by imitating an infection and stimulating the body’s immune system to respond as if it were a real infection (Centers for Disease Control and Prevention [CDC], 2019a). Vaccinations created by man, not by natural disease processes, have historically engendered controversy, suspicion, and in the Democratic Republic of Congo (DRC), violence (Nguyen, 2019). According to Link (2005), “vaccines are counterintuitive. What sense does it make to inject a well-baby with a potent, biologically active vaccine that contains elements of the very disease it is supposed to prevent?” (p. 38). Over the past decades, since the publication of the now retracted 1998 Wakefield and colleagues Lancet article asserting a link between measles, mumps, and rubella vaccines and childhood autism, fears of making well babies sick, rather than protecting them, have swelled. A recent cohort study that included over 650,000 children born in Denmark between 1999 and 2010 and followed up through 2013 confirmed no relationship between measles, mumps, and rubella (MMR) vaccinations and autism (Hviid, Hansen, Frisch, & Melbye, 2019). While the science is clear, however, fears and misinformation remain in some health care consumers’ and parents’ minds. Some of these fears are founded in well-grounded research and concerns about special populations and faulty vaccine preparation. Others are unfounded in any science and push false notions that vaccines are made with “monkey, rat, and pig DNA…cause autism, and are made from aborted fetuses” (Gostin, Ratzan, & Bloom, 2019; Pager, 2019, paras. 1, 6–7). A number of celebrities with no health knowledge or expertise have fanned these fears—and grown their followers—by ascribing to and promoting these ideas and conspiracy theories (New York Times Editorial Board, 2019; Roberts, 2018). Unfortunately, due to anti-vaxxer (i.e., people who don’t believe in vaccinations) disinformation campaigns, tens of thousands of children in the U.S. remain unvaccinated and potentially vulnerable to vaccine-preventable disease and death (Langer, 2018). Messages found on anti-vaccination websites play on values associated with individuality, freedom of choice, and religious beliefs and use persuasive communication techniques and misinformation, i.e., false, misleading, or distorted “facts,” to increase distrust of Big Pharma and the government. In addition, they repeat and amplify falsified research “findings” of autism and brain damage caused by vaccines (Moran, Everhart, Lucas, Prickett, & Morgan, 2015). Due to lack of immunization in other countries, porous borders, global travel, and parental refusals to vaccinate their children in this country, diseases we once thought we vanquished with vaccines are making a comeback, often in tragic ways. We are now seeing a resurgence of measles, polio, pertussis, and our old friend, influenza.

According to the CDC (2019b), “from January 1 to July 3, 2019, 1,109 individual cases of measles have been confirmed in 28 states, the second-greatest number of cases reported in the U.S. since measles was eliminated in 2000” (para. 1). One in four kindergarteners in Washington County, Washington is not fully vaccinated (Chodosh, 2019). Even if a child is vaccinated, they can still acquire measles from an unvaccinated child; about 3 in 10 vaccinated people can still become infected (CDC, 2018a).

Those 3 out of 4 other children in Washington County, Washington are put at risk the moment their unvaccinated classmate arrives at school. Infants, in particular, who have not yet gotten their MMR vaccination are at extreme risk. To put these numbers in perspective and provide more reasons why we should be alarmed, here are some other data:

■   “Before the measles vaccination program began in 1963, about 3-4 million people got measles each year in the United States. Of those people, 400-500 died, 48,000 were hospitalized, and 4,000 developed encephalitis (brain swelling) from measles” (CDC, 2018a, para. 5).
■   World-wide, measles cases are up 300% (Fore & Ghebreyesus, 2019).
■   Although some protest that measles has very few adverse effects, the World Health Organization (WHO, 2018a) reported “110,000 deaths globally…mostly among children under the age of five” (para. 1).
■   In Shanghai, “a single child with measles in a pediatric oncology clinic infected 23 other children, more than 50% of whom ended up with severe complications, and the case fatality rate was 21%” (Paules, Marston, & Fauci, 2019, para. 9).
■   The cost of responding to one measles case “can be as high as $142,000….In 2011, the estimated total cost of measles outbreaks in the United States ranged from $2.7 million to $5.3 million” (Sundaram, Guterman, & Omer, 2019, para. 7).
■   The WHO has named “Vaccine Hesitancy” as number 8 on the top 10 list of threats to global health in 2019 (WHO, 2019a, para. 26–29).
Public health officials are responding with stepped up vaccination information campaigns, emergency declarations, quarantines, and repealing non-medical reasons exemptions. The following are some examples:

In 2015, California passed vaccination legislation requiring all children to be vaccinated against diseases, including measles and pertussis (McGreevy & Lin, 2015). “The state repealed all non-medical exemptions within a year, including religious and philosophical” (Dor, Moghtaderi, & Richwine, 2019, para. 8). Dor and colleagues tracked vaccination rates post repeal and found a “3 percent increase in measles, mumps, and rubella (MMR) vaccinations and a 2 percent increase in other required vaccinations” (para. 10).
■   As of this writing, Washington State could be the next state to ban non-medical exemptions following the examples of California, Mississippi, and West Virginia (Moon, 2019).
■   In Rockland County, New York, when the number of confirmed measles cases reached 153, and public health authorities determined that over three-quarters of the children had received no MMR vaccinations, they declared a state of emergency and utilized an existing state law to forbid unvaccinated children (i.e., under 18 years of age) to go out in public until they received their MMR vaccinations (Li & Charles, 2019). A judge ruled against the ban, however, short-circuiting these efforts to contain this growing outbreak (Sellers, 2019).
■   On April 25, 2019, “Public health officials imposed quarantines at the University of California, Los Angeles and California State University, Los Angeles for over 200 students, faculty and staff…exposed to a confirmed case of measles and who cannot prove they have vaccinations against measles” (Drash, 2019a, para. 2–3).
■   In other countries, which have seen spikes in vaccine-preventable diseases, the response has been swift and enforced. Italy banned unvaccinated children from schools and saw an immediate surge in vaccinations (“Italy bans,” 2019).

Here are a few scientific facts about vaccine preventable diseases that are important to know as a health care manager:

■   Measles is highly contagious virus, not a bacteria as one ill-informed politician claimed (May, 2019). Measles can be transmitted via aerosolization, i.e., breathing the droplets of the virus in the same air as someone who has measles. The virus can live in a room for up to two hours in the airspace after an infected person has coughed or sneezed in the space.
■   Pertussis is a highly contagious respiratory disease caused by the bacterium Bordetella pertussis. It can also be transmitted via aerosolization, i.e., breathing the droplets of the virus in the same air as someone who has pertussis.
■   “Polio virus is very contagious. In the U.S., we have had no cases of polio because of vaccines. The virus spreads through contact with the stool of an infected person and droplets from a sneeze or cough. If you get stool or droplets from an infected person on your hands and you touch your mouth, you can get infected. Also, if you put objects, like toys, that have stool or droplets on them into your mouth, you can get infected.” (CDC, 2017a, para. 2). Infants and children are most at risk for this disease. One infected world traveler can bring polio virus back to the U.S. to unvaccinated children.
■   Ebola virus can only be transmitted through direct contact with body fluids that contain the virus. Health care workers who take care of the sickest, dying, and dead Ebola victims are at greater risk than the general population.
■   Immunization, i.e., stimulating the body with vaccines to create antibodies against a disease, currently prevents an estimated two to three million deaths every year (WHO, 2019b).
■   Measles, polio, pertussis, and influenza by themselves kill more people annually than Ebola did at the height of its worst outbreak.

Vaccine Preventable Outbreaks from 2008 to 2017 have been mapped in an interactive website which was originally created by the Council on Foreign Relations: http://www.vaccineswork.org/vaccine-preventable-disease-outbreaks/ (Vaccineswork, 2019). As you can see from this dynamic model, the rise of outbreaks directly corresponds with declines in vaccinations, thanks in large part to the spread of “Wakefieldism,” and, in some parts of the world, attacks on vaccinators and public health workers by terrorists (Garrett & Builder, 2014; Harlow & Summers, 2014; Nguyen, 2019). TABLE 17-1 provides an overview of selected vaccine-preventable diseases, the number of cases in the U.S., and the number of global cases and deaths as of April 2019. For more current data, please go to the CDC and WHO websites noted in this chapter’s references.

As a health care manager, you will be responsible for ensuring your organization is prepared for contagious outbreaks, from measles to Ebola. You will be required to work with clinicians to establish appropriate training and protocols in the event of an outbreak or epidemic. Part of this training must include an emphasis on teamwork and on “just culture,” which puts the focus on “what went wrong, not who caused the problem” (Barnsteiner, 2011, para. 6). In 2014, when former CDC Director Frieden blamed nurses in Texas for contaminating themselves with Ebola, he demonstrated a punitive approach (Steenhuysen, 2014). The nurses were not consciously reckless; the system set them up for failure. Quality improvement and patient safety are discussed in greater detail elsewhere in this text. Briefly, just culture distinguishes among:

■   “Human error—inadvertent action…slip, lapse, mistake;
■   At-risk behavior—behavior that increases risk where risk is not recognized, or is mistakenly believed to be justified; and,
■   Reckless behavior—behavioral choice to consciously disregard a substantial and unjustifiable risk” (Page, 2007, para. 8).
Hospitals must have sufficient resources on hand to take care of infectious patients if they present to the ED. Lacking these resources and appropriate quarantine facilities, nurses and health care managers have an obligation to collaborate and speak up (Buchbinder, 2014).

It is critical to ensure our communities and the populations we serve are informed about the importance of vaccinations. Health care managers are on the frontlines of outbreaks and epidemics. To protect the health of our nation, we must move our patients and communities to become protected against vaccine preventable diseases. As health care managers we must remember:

Vaccinations and Health Care Managers
At this point, a few of you may be saying, “Aside from ensuring my employees have their flu shot, this is not my job.” That would be a misperception. Anywhere health care managers are responsible for the health of a population, such as in Accountable Care Organizations (ACOs), which are “organized groups of physicians, hospitals or other providers jointly accountable for caring for a defined patient population” (Lake, Stewart, & Ginsburg, 2011, para. 1), they are responsible for the health care provided by those physicians. Likewise, as the proportion of physicians employed by hospitals continues to rise, the buck for the quality of the health care delivered stops with the chief executive officer (CEO) and the Board of Trustees (The Physicians Foundation, 2018). We haven’t even mentioned the Healthcare Effectiveness Data and Information Set (HEDIS), one of the most widely used sets of health care performance measures in the U.S. It is used in organizations like health care insurance companies, ambulatory care centers, public health clinics, or urgent care centers, where health care managers are employed (National Committee for Quality Assurance, 2018). Health care organizations with large databases have the ability to conduct big data analyses and to implement the recommendations from the 2013 Institute of Medicine report, Best Care at Lower Cost: The Path to Continuously Learning Health Care in America. They also have the ability to use better health literacy approaches to improve communication between health care providers and families. Where there is good teamwork, there is no disconnect between health care managers and health care providers. This, too, is the responsibility of health care managers. The bottom line is health care managers are responsible for the health of populations and for ensuring vaccinations are provided for a healthier population today and for future generations (Buchbinder, 2015; Institute of Medicine, 2013).

Violence in Health Care Settings

Almost daily, media outlets are filled with reports of violence, so much so that we almost become numb to them. An active shooter in a popular mall. A disgruntled employee returns to his former place of employment armed to kill. A student with mental health problems murders a favorite teacher, a classroom full of students, or goes on a campus rampage. In November 2018, an ED physician was murdered by her former fiance. Not only did he kill Dr. Tamara O’Neal, he shot and killed two other people (Brice-Saddler, 2018). When violence hits in health care settings, we are shocked and ask, “How did this happen?” These institutions, these sacred places, are supposed to serve and care for our loved ones. Yet in many instances they cannot protect our loved ones because of the nature of the settings themselves. The purpose of this section is to focus on health care professionals, provide a brief overview of violence in health care settings, provide definitions and examples of workplace violence, and urge you to be aware of and find ways to address and prevent violence as health care managers.

What Is Violence in Health Care Settings?
One of the challenges in writing about statistics on violence in health care settings is the data are not always collected in the same manner, using the same definitions across various reporting agencies and authors. For this discussion, we chose to use data from the Bureau of Labor (BLS); the Bureau of Justice (BJS); the CDC, the National Institute for Occupational Safety and Health (NIOSH); the Occupational Safety and Health Administration (OSHA); the National Violence Against Women Survey; and peer-reviewed literature published by epidemiologists, physicians, nurses, attorneys, law enforcement officers, criminologists, and forensic psychologists, as well as important papers from professional organizations.

Workplace violence is “…the act or threat of violence, ranging from verbal abuse to physical assaults directed toward persons at work or on duty. The impact of workplace violence can range from psychological issues to physical injury, or even death” (NIOSH, 2018, para 1). The U.S. Department of Labor (DOL) defines it as “An action (verbal, written, or physical aggression) intended to control or cause, or capable of causing, death or serious bodily injury to oneself or others, or damage to property….includes abusive behavior toward authority, intimidating or harassing behavior, and threats” (DOL, n.d., para. 14).Violence in health care settings can occur against workers, clients/residents, visitors, relatives, i.e., anyone physically present in a health care setting. “Healthcare and social assistance workers were victims of approximately 11,370 assaults by persons; a greater than 13% increase over the number…reported in 2009. Almost 19% (i.e., 2,130) of these assaults occurred in nursing and residential care facilities alone” (OSHA, 2012, para. 1). In 2017, 85 health care workers and support personnel died while at work (BLS, 2018). Violence in health care settings is on the rise—and those numbers are grossly underreported. “From 2005 through 2009, of the occupational groups examined, law enforcement occupations had the highest average annual rate of workplace violence (48 violent crimes per 1,000 employed persons age 16 or older), followed by mental health occupations (21 per 1,000)” (Harrell, 2011, p. 4 ). As can be seen in FIGURE 17-1, while under 20% of all workplace injuries happen to health care workers, health care workers suffer 50% of the assaults.

According to the Emergency Nurses Association (2010), threats and violence are underreported because some employees assume that it’s part of the job or are fearful of reporting the incident to their supervisor because they are afraid of poor performance appraisals. These are sentinel events, i.e., unexpected occurrences involving death or serious physical or psychological injuries, or the risk thereof in health care settings which must be reported to The Joint Commission (TJC). Due to concerns about increases in workplace violence, TJC (2018) issued a Sentinel Event Alert (SEA) specifically on physical and verbal violence against health care workers to help employees and employers recognize and address this issue. Violence has no place in health care settings. Preventing workplace violence is the responsibility of health care managers.

Types of Workplace Violence
Violence in health care settings includes, but is not limited to:

■   Verbal abuse, including racial and ethnic slurs;
■   Worker-to-worker bullying;
■   Stalking and harassment;
■   Assault and battery; and,
■   Homicide.
Sexual harassment of health care workers is addressed in detail in another chapter in this text. Due to the dearth of data on rapes of health care workers, we will not address that topic in this section, either. However, rape is a specific form of physical assault—one that haunts survivors throughout their lives. Managers must be aware that sexual assaults and rapes of health care workers can happen, and you must be prepared to deal with cases in a sensitive manner, preferably with the assistance of certified Forensic Nurse Examiners (FNE). Before we can discuss how to prevent violence in health care settings, we will define it and provide examples for you

Verbal Assault
Verbal abuse is assault, i.e., “attacking someone physically or verbally, causing bodily or emotional injury, pain, and/or distress. This might involve the use of a weapon, and includes actions such as hitting, punching, pushing, poking, or kicking” (DOL, n.d., para. 1). For the most part, the definition of physical assault is undisputed, i.e., there is an aggressive action, a perpetrator and a victim, and physical outcomes. Verbal abuse and assault, however, often go unreported because it is subjective and can be explained away by the perpetrator or others, such as supervisors who don’t like confrontations. Commonly used phrases to downplay verbal abuse are: “You must have misunderstood them,” “Work it out yourself,” “You’re being paranoid,” “He really didn’t mean it,” or “She was upset/in pain/distraught.” These behaviors invalidate the victim’s complaints and make the victim appear to be a problem employee, a troublemaker. Perpetrators of verbal assault against health care workers can be patients, visitors, vendors, co-workers, supervisors—anyone in the workplace. TEXTBOX 17-1 provides an example of verbal assault against an RN.

Bullying
Intimidation and harassment are “threats or other conduct which create a hostile environment…frighten, alarm, or inhibit others” (DOL, n.d., para. 8). While this can certainly occur with visitors, vendors, and other non-health care workers, the most common form of this behavior between health care workers is bullying, also known as horizontal violence (peer to peer) and vertical violence (supervisor to employee). This systemic, ongoing pattern of targeting and harassing of a victim can be conducted by one or more co-workers and include: “Verbal abuse, threatening, intimidating or humiliating behaviors, and work interference…Additionally, there are five recognized categories of workplace violence: threat to professional status, threat to personal standing, isolation, overwork, and failing to give credit where credit is due” (TJC, 2016, para. 4). One survey found “over half (50%) of 10,688 nurses and nursing students experienced verbal abuse in a 3 year period, 2013-2016” (American Nurses Association, 2016, p. 4). Some research indicates that mediation and apologies can mitigate the damaging effects of bullying (Fox & Stallworth, 2003, 2006). However, the apologies must be sincere, and the actions that follow should be consistent with the intent to repair the relationship. TEXTBOX 17-2 provides an example of co-worker bullying behaviors.

Stalking
The DOL (n.d.) defines stalking as a “malicious course of conduct that includes approaching or pursuing another person with intent to place that person in reasonable fear of serious bodily injury or death to him/herself or to a third party” (para. 12). Baum, Catalano, and Rose (2009) add to this definition with examples: unwanted communications or social posts of any sort, “following or spying on the victim, showing up places…without a legitimate reason, waiting at places…for the victim, leaving unwanted items, presents, or flowers; posting information or spreading rumors about the victim” (p. 1).

In the National Violence Against Women Survey, using a strict definition of stalking, i.e., the victim felt a high level of fear, the authors found that “8 percent of the women surveyed were stalked versus 2 percent of men have been stalked at some point in their life” (Tjaden & Thoennes, 1998, p. 3). About half of the victims of stalking, both male and female, reported their concerns to police. Police were more likely to intervene when the victim was a woman. Of those who did not report their complaints, the top three reasons for non-reporting were: “did not think it was a police matter, thought police couldn’t do anything, or feared reprisal from stalker” (Tjaden & Thoennes, 1998, p. 10). When compared to individuals who had never been stalked, stalking victims reported “more fears for their personal safety and being stalked, carried something on them for personal safety, and felt things had gotten worse in general for men and women with regard to personal safety” (Tjaden & Thoennes, 1998, p. 11).

Stalking is an underreported phenomenon (Davis & Chipman, 1997; Logan, 2010). Victims are embarrassed, unwilling to disclose their concerns for fears of being ridiculed, or worse, for fear of losing their job. In addition, victims are often in the throes of domestic troubles that may have already spilled over into violence, and fear reprisal from their stalkers. Stalking can last an average of two years and can escalate into aggravated assault and homicide, especially if the stalker is an intimate partner (Logan, 2010; Tjaden & Thoennes, 1998). Concannon (2005) found “individuals who engaged in stalking behaviors with greater frequency over the course of one year were significantly more likely to be violent than were those who did not engage in such behaviors or who engaged in such behaviors on a less frequent basis” (p. vi). Fear of the stalker, feelings of helplessness, and being overwhelmed contribute to the victim’s fear of job loss—if they dare to share their terror. The National Center for Victims of Crime (2011) has a Stalking Resource Center (2011), which includes definitions, data, and resources for stalking victims.

In the case of health care professionals, stalkers are more common among mental health professionals. One of the few available studies on the actual prevalence of stalking of mental health professionals found that “5% of counseling center staff had been stalked by current or former clients, 8% had a family member stalked, and over half (65%) had experienced harassment” (Romans, Hays, & White, 1996, p. 595). Stalking can last over a period of a few months to several years (McIvor & Petch, 2006; Mullen et al., 2006). The obsessive stalker can be male or female, personality disordered and/or substance abusing, and may be in search of “intimacy or are ex-partners unwilling to abandon the lost relationship” (Mullen et al., 2006, p. 440). TEXTBOX 17-3 provides an example of stalking behaviors.

Physical Assault
Between 1993 and 1999, the “majority (94%) of workplace crimes were simple and aggravated assaults” (Duhart, 2001, p. 5). There were four simple assaults for every aggravated assault. Assault rates were highest among mental health care workers. ED physicians also reported high rates of assault, with one in four (25%) of responding physicians having been physically assaulted (Kowalenko, Walters, Khare, & Compton, 2005). The BJS found assailants were most likely to be male, most likely to be of a similar racial group to the victim, most likely to be young, and had about a one in three chance of being under the influence of alcohol or drugs at the time of attack (Duhart, 2001). More recently, the American College of Emergency Physicians (ACEP, 2018) conducted a national survey and found “Nearly 50 percent of emergency physicians have been assaulted while at work in the emergency department, while over 70 percent have witnessed another assault. Only 10 percent have experienced neither” (p. 6). Comparing the 2005 and 2018 statistics, these data present an alarming picture of rising violence in the ED. TEXTBOX 17-4 provides an example of assault in an ED.

Homicide
Homicides in health care organizations are rare events and data are sparse for settings across the continuum of care. We do have data for hospitals, where “…in the period from 2003 to 2011, there were 263 work-related fatalities…an average of 24 per year…76 of the 263 (29%) fatalities were caused by violence (approximately half homicides and half self-inflicted ” (see FIGURE 17-2) (OSHA, 2013, p. 6).

For the most part, health care workers, in general, have a lower rate of homicides than other occupations. However, with respect to women, while their overall numbers were lower than males for violent crime, when they were targets of violence in the workplace, women were more likely to be killed at work and were more likely to be killed by someone they know and/or an intimate partner. These homicides do not appear in a vacuum. Oftentimes, victims have reported domestic violence incidents to the police and have obtained restraining orders against their partners. Employers may take the easy route and fire an employee who has issues with domestic violence (DOJ & Federal Bureau of Investigation, 2002). In health care settings, this type of callous response is unconscionable. The next time a supervisor sees that employee, they could be dead on arrival in the ED.

According to NIOSH (2001), “homicide accounts for 40% of all workplace deaths among female workers; over 25% of the homicide victims are assaulted by people they know, and 16% are victims of domestic violence that spills over into the workplace” (para. 1). At some point in a tumultuous relationship, intimate partners become murderers. Oftentimes before the murder occurs, there have been warning signs, such as harassment; emotional, psychological, and physical abuse; and stalking. Many women are reluctant to tell co-workers they are going through an ugly separation or divorce. This shame can cost them their lives and the lives of others. The murder of Dr. Tamara O’Neal is a case in point of domestic violence coming to the ED door with the intent to kill. How could Dr. O’Neal’s death and the deaths of others have been prevented? We will address that next.
Risk Factors for Workplace Violence
According to OSHA (2016), there are 15 risk factors for violence in health care settings. They are:

Patient, Client and Setting-Related Risk Factors

•    Working directly with people who have a history of violence, abuse drugs or alcohol, are gang members, and are relatives of patients or clients;
•    Transporting patients and clients;
•    Working alone in a facility or in patients’ homes;
•    Poor environmental design of the workplace that may block employees’ vision or interfere with their escape from a violent incident;
•    Poorly lit corridors, rooms, parking lots and other areas;
•    Lack of means of emergency communication;
•    Prevalence of firearms, knives and other weapons among patients and their families and friends; and,
•    Working in neighborhoods with high crime rates.

Organizational Risk Factors

•    Lack of facility policies and staff training for recognizing and managing escalating hostile and assaultive behaviors from patients, clients, visitors, or staff;
•    Working when understaffed—especially during mealtimes and visiting hours;
•    High worker turnover;
•    Inadequate security and mental health personnel on site;
•    Long waits for patients or clients and overcrowded, uncomfortable waiting rooms;
•    Unrestricted movement of the public in clinics and hospitals; and,
•    Perception that violence is tolerated, and victims will not be able to report the incident to police and/or press charges (OSHA, 2016, pp. 4–5).
As you can see, 10 of the 15 (67%) risk factors are directly under the control of health care managers. Even the ones not directly under the health care manager’s control can be mitigated by judicious application of preventive measures. In addition, based on the above, one can surmise that mental health and ED workers will have the greatest risks. Violence in the community begets violence in health care settings. These workers deal with the sequelae of mental health issues and violence in the community on a daily basis. When patients overdose on opioids; succumb to mental health crises; or are shot while in church, school, or movie theaters, violence moves to the ED. One study found that 29% of ED shootings between 2000 and 2011 occurred when the patient was accompanied by a law enforcement officer and attempted escape (Kelen, Catlett, Kubit, & Hsieh, 2012). Oftentimes, the gun used was the officer’s own weapon. When gun lobbyists told physicians and nurses to “stay in your lane,” trauma doctors and nurses responded with data, graphic photos, and personal stories on Twitter, Instagram, and elsewhere with the hashtag #thisismylane (Choo, 2018). As health care managers, this is your lane, too.

Consequences, Costs, and Planning
In addition to the physical consequences of assault, emotional and mental sequelae take a significant toll on victims and witnesses of violence (Gillespie, 2008). A previous chapter addressed the high cost of health care professionals’ turnover. Violence is a factor in increasing absences from work, greater use of workers’ compensation claims, sick time, quits, and personal injury lawsuits, and the costs add up. From a business perspective, it makes good sense to have a violence prevention plan in the workplace. FIGURE 17-3 shows the impact of violent injuries on health care workers by job title and cause of injury. When you translate those days away from work into sick time, worker’s compensation claims, and lawsuits, this is a human and financial expense every manager should want to avoid.

Creating a safe workplace requires the commitment of health care managers and engaging the health care team in coming up with a safety plan for everyone. A safety committee should be convened with the departments most affected by violence. At a minimum, representatives from Security, the Emergency Department, Mental and Behavioral Health Department, , Medicine, Management, Human Resources (HR), and Research/Data Analysis must be present at the table. They must also be held accountable for participating fully in the work of the committee and following through. The committee must have resources to benchmark other health care organizations’ violence prevention policies and plans, as well as planning, recommending, implementing, and evaluating a violence prevention intervention tailored to meet that organization’s needs. “Resource needs often go beyond financial needs to include access to information, personnel, time, training, tools, or equipment” (OSHA, 2016, p. 6).

As part of the committee’s fact-finding, data will be needed to determine which departments and employees are most at risk. We must not assume that we know where the most incidents occur; data must be collected and analyzed by location, victim’s job title, activity, time of day, type of violence, and the role of the perpetrator (e.g., visitor, vendor, co-worker, etc.) among other information that the committee deems to be important (OSHA, 2016). In addition to collecting data about violent incidents, near misses should be recorded, too. The plan must be data-driven through understanding the incidents and near misses. The committee must survey patients, clients, employees, visitors, and other stakeholders to obtain a 360º view of perceptions of safety in the workplace. Included in these surveys should be requests for suggestions for change. Some of the best solutions to the worst problems can come from unexpected sources.

After the data are in and the areas at risk are determined, the committee should conduct rounds in the physical plant with a checklist for safety—a checklist that has been created by the committee. OSHA (2016) has a list of suggested items to review as part of a risk analysis, e.g., questions about adequate lighting, safe places, visitor badges, overcrowded waiting rooms, wait time, and physical layouts.

Training and counseling programs need to be included in the violence prevention plan and policy. Topics should include, but not be limited to violence prevention, conflict management and de-escalation, self-defense, and post-trauma debriefing and counseling. HR will be instrumental in creating and implementing these training events and modules in sync with the development of interventions. Once the problem areas are determined, a Plan Do Study Act (PDSA) cycle can be implemented for interventions using one department as the pilot. If the PDSA goes well, the intervention can be replicated across the organization and tailored for each department, activity, or employee category.

Many excellent resources for developing workplace violence prevention plans are available online. The American Society for Health Care Risk Management (n.d) has a downloadable checklist that encompasses everything from pre-employment screening to after the incident and post-trauma interventions. The Emergency Nurses Association (ENA) (2010) has an ENA Workplace Violence Toolkit, which provides health care professionals with a step-by-step plan for addressing violence in the ED. In addition, OSHA (2016) has Guidelines for Preventing Workplace Violence for Health Care & Social Service Workers, and the New York State Department of Labor (2009) has Workplace Violence Prevention Program Guidelines, to name but a few. The video from the Department of Homeland Security (2017) on active shooter scenarios is also an excellent resource, as well as ZDoggmd.com, a website featuring a physician-singer-activist, who is passionate about safety. Whether we want to think about it or not, workplace violence in health care settings is a real phenomenon that won’t go away by ignoring it. As health care managers, it is incumbent upon us to protect our workers, employees, patients, and families from those intent on bringing violence to health care settings.

Mental Illness, Substance Use Disorders, and Federal Legislation

Two centuries after the Spanish conquistadores arrived in the Southwest seeking gold and leaving a swath of genocide in their path, the Pilgrims arrived in what is now Massachusetts (History.com Editors, 2018a, 2019a). “The group that set out from Plymouth, in southwestern England, in September 1620 included 35 members of a radical Puritan faction known as the English Separatist Church” (History.com Editors, 2009, para. 2). The Puritans deemed any deviance from their strict rules as sinful—and in a particularly historic series of events, witchcraft. Governed by the English legal system, Salem Village court scribes recorded each word uttered throughout the infamous Salem Witch Trials (Boyer & Nissenbaum, 1977; University of Virginia, 2002). These legal records provide a detailed example of how far a religious group led by a zealous and ambitious preacher would go to suppress and punish all who did not follow their rules. Among other “crimes,” the most noted female rule-breakers were “Tituba, a slave from Barbados…a disheveled beggar named Sarah Good and the elderly Sarah Osburn” (National Geographic Staff, 2017, para. 11). The Puritanical religious framework considered deviance from “normal” behaviors a moral choice and the devil’s work. The dichotomy between religious beliefs and evidence-based science and medical care continues to pervade U.S. health care politics and policies today, including issues surrounding mental health and substance abuse.

Mental Health Services in the United States
In 1751, Benjamin Franklin and Dr. Thomas Bond established the first hospital in the nation. Created to treat the poor, Pennsylvania Hospital was the first “to treat psychological and emotional disorders as conditions that could be cured” (History of Pennsylvania Hospital, 2017, para. 5). In 1792, Philippe Pinel, physician and father of modern psychiatry, convinced the new French post-revolution government to free “lunatics” from dungeons and chains in Paris. He promoted humane treatment of the mentally ill, an approach based on a religious foundation called moral treatment (Trent, 2018). Benjamin Rush, physician, signer of the Declaration of Independence, founder of American psychiatry, and medical staff member of Pennsylvania Hospital, also adhered to moral treatment.

A century after the establishment of Pennsylvania Hospital, relentless reformer Dorothea Dix urged the creation of the nation’s first Government Hospital for the Insane, i.e., St. Elizabeths Hospital in Washington, D.C. (Overholser, 1953/1956). In 1852, Congress appropriated $100,000 for an asylum for “the insane of the District of Columbia, the Army, and the Navy” (Overholser, 1953/1956, p. 267). This large institution, which provided a parklike setting with trees, gardens, kind attendants, and welcoming areas for visitors, became a field hospital for the Civil War, serving both the blue and the gray (Overholser, 1953/1956). Originally intended to house only 90 resident patients at full capacity, St. Elizabeths served the wounded in the Civil War, and in 1862, “there were 357 patients in the hospital, making it the largest of its kind in the country” (Overholser, 1953/1956, p. 271). Over the years, the patient population burgeoned and by September 2, 1945 (V-J Day), St. Elizabeths housed 7,460 patients (Overholser, 1953/1956, p. 279).

Across the course of time, treatment methods at St. Elizabeths, and at similar facilities in the country, changed with advances in psychiatry. Psychiatrists employed various therapies with the seriously mentally ill in restrictive settings. These approaches included, but were not limited to: talk therapy, straitjackets, art therapy, psychodrama, occupational therapy, hydrotherapy, and insulin and electric shock therapy (Franz, 1946; Herriott & Hagan, 1941; Overholser, 1953/1956; Richard, 1984). For those non-responsive to these approaches, frontal, or pre-frontal lobotomy, also known as leucotomy, the invasive and life-altering brain surgery that severed the white matter connecting the two prefrontal lobes of the cortex, was hailed as a miracle cure in the mid-1940s in the U.S. (El-Hai, 2007). Drugs that treated emotional and psychological diseases did not become available until the 1950s when chlorpromazine, aka, ThorazineTM led the world into the psycho-pharmaceutical era (Frontline, 2005).

Deinstitutionalization
If you have ever seen the 1975 major motion picture, One Flew Over the Cuckoo’s Nest, you will undoubtedly recall the evil Nurse Ratched, played by Louise Fletcher. Con artist R.P. McMurphy, who is played by Jack Nicholson, pretends to be insane so he can be committed to the relative luxury of a mental hospital instead of going to prison (Douglas, Fink, Zaentz, & Forman, 1975). While in the locked facility, McMurphy runs afoul of Nurse Ratched and stirs up trouble with the other patients. Medications and other approaches don’t control the wily McMurphy, so Nurse Ratched gets her revenge by having McMurphy lobotomized. At the end of the film, McMurphy is a drooling, compliant patient, just another one of the obedient regulars under her care. One Flew Over the Cuckoo’s Nest, based on the novel of the same name by Ken Kesey, is the embodiment of all the prevailing fears of the era regarding institutionalization for mental illness (Kesey, 1962; Yohanna, 2013). These fears, combined with advances in drug therapy, the Civil Rights Movement, and state budget cuts to psychiatric hospitals led to what some call “a psychiatric Titanic,” i.e., the deinstitutionalization and removal of the seriously mentally ill from psychiatric hospitals (Torrey, 1997, in Frontline, 2015, para. 10).

Per E. Fuller Torrey, a world renowned psychiatrist who practiced for many years at St. Elizabeths, “In 1955, there were 558,239 severely mentally ill patients in the nation’s public psychiatric hospitals. In 1994, this number had been reduced by 486,620 patients, to 71,619” (Torrey, 1997, in Frontline, 2005, para. 3). This massive shift of patients to “least restrictive settings” (Torrey, 1997, in Frontline, 2005, para. 9) was supposed to be supported by a safety net of Community Mental Health Centers (CMHCs). Instead, little to no planning for medications and rehabilitation took place in the communities whence they were discharged. In New York State, for example, “Between 1965 and 1979 alone, the number of resident patients in State psychiatric centers fell from 85,000 to 27,000 patients, a 68 percent decline” (Coalition for the Homeless, n.d., para. 5). Despite massive savings from these closures, New York State and many other states did not invest in the needed community infrastructure to serve this newly homeless and sick population. As modest as they were, single room occupancies (SROs), boarding rooms, and inexpensive hotels provided many of these traumatized people a place to live and try to regain their bearings and their lives.
In 2014, “about 18.1 percent, or 43.6 million adults had any mental illness (AMI) in the past year, and 4.1 percent (9.8 million adults) had serious mental illness (SMI)” (Center for Behavioral Health and Quality, 2015, p. 3). For that same year, “…over 170,000 residents were in inpatient and…residential treatment beds on any given night…a 64 percent decrease…from 1970. When data are adjusted for the growth in the population of the United States since 1970, the decline in beds is…77.4 percent” (NRI, 2017, para. 4). Many of those who were deinstitutionalized in the 1970s—and are still alive—reside in their own homes, nursing homes, or other facilities that provide dementia care, thanks to the enactment of Medicaid and Medicare in the 1960s (NRI, 2017). Over three-quarters of our homeless veterans have SMI, and many of them also have substance use disorders (VA, 2017). Veterans are not the only people with mental illness who have substance use disorders (SUDs). As you can see from FIGURE 17-4, the overlap is significant. Treatment of these co-occurring or comorbid conditions (comorbidity) and dual diagnoses can be quite challenging (National Institute on Drug Abuse [NIDA], 2018). Not all psychiatric facilities will treat SUDs at the same time, and not all drug rehabilitation facilities will treat psychiatric conditions at the same time. Similar to the chicken and the egg question, substance use can cause mental illness and mental illness can cause substance use. Complicating this matter is the fact that research indicates that SUDs are a form of self-medication for mental illnesses such as anxiety, depression, and bipolar disorders (Santucci, 2012).

Drugs and Mental Illness
Well before the advent of chlorpromazine in the 1950s, physicians employed a wide variety of drugs to treat mental illness. In 1877, at St. Elizabeths, Dr. Godding, “an abstainer from alcohol and tobacco…permitted the use of alcohol in feeble and infirm cases” (Overholser, 1953/1956, p. 274). Opium, laudanum, morphine, cocaine, and paregoric (a camphorated tincture of opium) were commonly part of a well-stocked household medicine chest, used by housewives and physicians to treat coughing, diarrhea, dyspepsia, toothache, restlessness (mania), melancholia (depression), and severe pain (e.g., burns and cancer) in adults. Children who did not sleep well (including infants) often received paregoric to allow mothers and nannies to get some rest—sometimes with deadly consequences (Gray, in press; Jones et al., 2018). Heroin, a morphine derivative, was hailed as a wonder drug that could treat a multitude of ailments (United Nations Office on Drugs and Crime, 1953). In the 19th century U.S., absence of physician knowledge of the negative potential of opiates led consumers to believe the use of opium and its cousins was safe. On the contrary, many users required higher doses to achieve the same effect, i.e., tolerance. Physical tolerance can lead to physical dependence, i.e., physical and psychological signs of withdrawal if the drug is stopped, and addiction, the compulsive urge to use a drug (including tobacco and alcohol) even when no longer medically necessary (U.S. National Library of Medicine, 2019).

At first unrecognized due to the commonality of use of opiates as a household item, over time opiate use became a national problem. “At the urging of the Treasury Department the Supreme Court ruled in March 1919 that physicians could not maintain addicted patients…[and] many addicts, denied a legal source of opiates…turned to the black market” (Courtwright, 1983, p. 58). “In response to this event, many municipalities created narcotic clinics…to supply narcotics and…to treat addicted persons” (Courtwright, p. 58). By 1921, the federal government shut these compassionate clinics down. Despite these efforts, the opiate problem continued. In 1924, three years before the Great Depression, “southern whites had the highest addiction rate of any regional racial group in the country, and perhaps one of the highest in the world” (Courtwright, p. 57) with Shreveport, Louisiana leading the nation with “9.55 addicts per thousand persons… nearly 9.7 times as great as the overall average” (Courtwright, p. 59). As you will see in the next section, the U.S. Treasury Department and other federal agencies have been instrumental in developing increasingly harsh laws to control the import, export, and distribution of drugs—to levy taxes and assess greater and greater fines in an effort to bury the problem. Unlike simple problems that have an easy fix, opiate use is a wicked problem. Like a basketball pushed under water, the opioid epidemic continues to erupt through the surface of failed drug policies and laws.

Federal s, Drugs, and Pain Management
Multiple federal laws designed to regulate and tax the import, distribution, and use of opium and its related products have lurched from decade to decade, fighting popular opinions and forcing opioid addiction into the shadowy underworld of illegal acquisition and sales. Redford and Powell (2016) say the U.S. “War on Drugs” began with the Harrison Narcotics Tax Act in 1914, which sought “to impose a special tax on all persons who produce, import, manufacture, compound, deal in, dispense, sell, distribute, or give away opium or coca leaves, their salts, derivatives, or preparations…” (Harrison Narcotics Tax Act, 1914, para. 2). Whereas before this tax law went into effect opiate users were not stigmatized, now addicts were depicted as criminals and low-lifes in the popular press (Garner, 2014). These tactics failed to control the flow of opiates in the U.S., as well as the behaviors of both prescribers and patients (King, 1953).

Prohibition
Around the same time the Harrison Act was becoming law, Americans fell under the spell of reformation and the Woman’s Christian Temperance Union (WCTU), a movement linked to evangelical Protestants and the Ku Klux Klan (KKK) (Abbot, 2007; Little, 2019; Parrett, 2016). Carrie Nation, the widow of an alcoholic and leader of the WCTU was often photographed with a Bible in one hand and an ax in the other. WCTU crusaders sought to abolish tobacco, alcohol, and prostitution, and charged into bars and brothels, smashing bottles and terrifying customers (Dvorak, 2019; Library of Congress, 2013). Over the course of several decades, the WCTU and the KKK, enraged by the influx of Catholic and Jewish immigrants, whom they saw as “others” and “dirty and drunk,” led the charge to abolish alcohol distribution and use in the U.S. (History.com Editors, 2018b; Little, 2019). Carrie Nation did not live to see the enactment of the 18th Amendment in 1919, also known as the Volstead Act and Prohibition (Dvorak, 2019). A little over a decade later, in 1933, a nation that claimed no spirits would ever touch their lips repealed the 18th Amendment with the 21st Amendment and bars re-opened for business.

In the intervening 14 years, Chicago’s Al Capone became rich through his thriving speakeasies and bootleg and drug running business. He also became notorious for Thompson submachine guns, gangsters, and murders (Mob Museum, n.d.). A young and ambitious Prohibition Agent, Elliott Ness, and his Untouchables became national heroes, chasing Al Capone and other infamous gangsters of the era, inspiring movies and the iconic comic strip, Dick Tracy (Bureau of Alcohol, Tobacco, Firearms and Explosives (ATF), 2016; Collins & Schwartz, 2018). What’s missing in many of the Hollywood depictions of this era is the senseless violence and loss of lives due to a Puritanical framework of moral intolerance. Carrie Nation was angry and bitter when her alcoholic husband died and left her to raise her child alone. She turned her tragedy into a vendetta against all who drank alcohol. The members of the WCTU did not perceive alcoholics as ill; instead they persecuted them as weak with low moral character and no will power. When you see this type of bias and judgmental behavior toward alcoholics and substance abusers as a health care manager, you must always ask yourself this question: Why? What histories and preconceived notions do these people have that makes them behave in this manner? If you are able to understand the root of someone’s biases, you have an opportunity to address this, especially if the person is your employee.

Federal s Regulating Drug Use
TABLE 17-2 provides an overview of the history of major U.S. alcohol and drug laws, the rationale for the laws, and the effects of the laws. Some of the effects of these laws are not seen immediately which is why we need to have the long lens of history to look back on where we came from to give us a sense of where (and why) we are now at this point in history. Hopefully, it will also give you an idea of what future directions should be.

Controlling Narcotics
The Boggs Act of 1951 and the Narcotics Control Act of 1956 imposed criminal penalties and mandatory prison sentences for violations of existing laws. Despite the escalating punishments and fines, demand for opiates continued. The federal government responded with more laws: The Controlled Substance Act of 1970 and the Controlled Substances Import and Export Act of 1970. The first law consolidated all narcotics under one “umbrella” and categorized the drugs by Schedules, with “Schedule I drugs, substances, or chemicals defined as drugs with no currently accepted medical use and a high potential for abuse” (DEA, n.d.a, para. 3). Included in this list are “heroin, lysergic acid diethylamide (LSD), marijuana (cannabis), 3,4-methylenedioxymethamphetamine (ecstasy), methaqualone, and peyote” (DEA, n.d., para. 3). Even these drugs have exceptions. In 1994, the Native American Church was able to obtain an exception for the use of peyote for religious purposes (American Indian Religious Freedom Act, 1994). Schedule II covers the drugs with high potential for abuse and addiction (opiates and amphetamines) and goes down to Schedule V which delineates drugs least likely to cause abuse and addiction (e.g., anti-tussives and anti-diarrheals) (DEA, n.d.). More recently, over 30 states have legalized marijuana for medicinal purposes, and in some, for recreational use (“State marijuana laws,” 2018). However, per federal law, marijuana is still illegal and a Schedule I drug. The second law, Controlled Substances Import and Export Act of 1970, made it illegal to import and export controlled substances in Schedules I or II and narcotic drugs in Schedules III, IV, or V—with exceptions for specific circumstances, e.g., medical research—and non-narcotic controlled substances in Schedule III, IV, or V (Controlled Substances Import and Export Act of 1970).

Between 2000 and 2006, more federal laws were enacted to allow physicians to treat SUDs and opiate use disorders (OUDs)—with specific restrictions (see Table 17-2). Methadone can only be distributed at Substance Abuse and Mental Health Services Administration (SAMHSA)-certified clinics and patients must come daily to receive the medication. Buprenorphine can only be used by physicians who have received DEA training; initially, they could only treat 30 patients. In 2005, SAMHSA evaluation research on the use of medication treatment (MT) found it to be safe and effective, with minimal clinical and public health adverse effects or drug diversions. Congress increased the number of patients physicians could treat with the DEA waiver (SAMHSA, 2019). Because of its safety, some physicians are now recommending that buprenorphine should available over-the-counter (OTC) (Roy & Stein, 2019). The third MT for OUD, Naltrexone, can be administered by any licensed health care professional. The good news is more people with OUD are being treated by a greater variety of physician specialties (Mojtabai, Mauro, Wall, Barry, & Olfson, 2019; Wen, Borders, & Cummings, 2019). The bad news is that in rural areas, due to the Ryan Haight Online Pharmacy Consumer Protection Act of 2008, there has been lower use of telemedicine to treat SUDs relative to use for mental health disorders in part due to restrictions on where and how patients can be seen (American Psychiatric Association, n.d.; Huskamp et al., 2018). As Leshner and Dzau (2019) said, “opioid use disorder is a chronic brain disease, not simply a moral failing” (p. E1). Evidence-based MTs are available for OUDs and can save lives—but legal restrictions on MT continue to stigmatize and criminalize those who suffer from the disease (Leshner & Dzau, 2019). As we move into an era of increasing reliance on telemedicine and demand for better treatment of SUDs and OUDs, and changes in laws regulating drugs, health care managers must keep up with all the regulations associated with prescribing practices.

Pain and Predators
Even as laws were put into place to control the distribution and flow of opiates and other drugs, multiple organizations pointed out that many countries were mistaken in not allowing physicians to use opiates for pain relief. The World Health Organization (1986) addressed the need for pain relief for cancer, in particular, and discussed barriers to use of opiates to alleviate pain. The American Pain Society (APS) “launched its pain as the fifth vital sign campaign in 1995,” followed by the Veterans Administration doing the same (Jones et al., 2018, p. 15).

In 1997, as the pain management campaigns were growing, a physician-founded pharmaceutical company, Purdue Pharma (bought in 1952 by the Sackler family), entered a new drug into the marketplace: OxyContin. Marketed to physicians as a pain medication on a par with codeine, Purdue hired hundreds of drug detail salesmen and women and deployed them to prescribers’ offices to hard-sell the new medication (Armstrong, 2019; “Family behind OxyContin,” 2019). Videos and sales materials provided to physicians claimed that less than 1% of patients would become addicted to opioids, and that pain, not opioids, blurred patients’ minds (Armstrong, 2019). Court documents revealed the Sacklers knew OxyContin was addictive and ordered their sales and marketing team to hide the risks of the drugs from physicians. In an internal email to marketing, Richard Sackler, president and CEO of Purdue Pharma, instructed drug detailers to tell physicians it was the patient’s fault, not the drug if they became addicted (Armstrong, 2019). Since addicts had already been demonized since the Harrison Narcotics Tax Act in 1914, this moral manipulation fed into the preconceived biases of many health care providers. However, any physician or nurse who has passed their licensure examination knows all narcotics have the potential to be addictive. Purdue Pharma’s lies do not excuse overprescribers for their complicity in the opioid epidemic.

Concomitant with Purdue Pharma’s aggressive sales pitches, when TJC published its pain standard in 2001, hospitals and health care organizations were put on notice that they would be judged on how well they managed patients’ pain levels, based on patients’ self-assessment (Baker, 2018). The pendulum of opiate control continued to swing in favor of greater pain management in 2005 with Public 109-56, the Amended Controlled Substances Act that lifted the patient limitation on prescribing drug addiction treatments by medical practitioners in group practices and for other purposes. This meant patients with intractable pain from cancer, burns, and other disabling conditions could finally seek relief without worry of being arrested—and physicians could also be free to prescribe needed medications—or overprescribe them. Pushing the pendulum more, the DEA, the agency responsible for control of all Scheduled drugs, gave permission to step up production of opioid-related products by 200% between 2006 and 2014 (DEA, 2019; “Ten things,” 2019).

Early signs appeared to indicate the pain standard was creating unintended consequences and that some physicians were “overzealous” in pain management (Baker, 2018, p. 1117). Hospitals and health care providers concerned about not meeting TJC standards and Centers for Medicare and Medicaid Services (CMS) Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) pain measures—which impact reimbursements—stepped up the use of opioids. TJC tried to claw back the standard and soften the language from “pain is the 5th vital sign” to “pain used to be the 5th vital sign” to “deleting the phrase from accreditation standards manuals in 2009—except for patients receiving behavioral health care” (Baker, 2017, p. 1118; TJC, 2019). However, the genie—OxyContin—was already out of the bottle. Purdue Pharma funneled millions of dollars into the “pain is the 5th vital sign” campaigns, further legitimizing their hard-sell of OxyContin. They built up demand (“Bad doctors, bad hospitals, you are under-treating pain!”) and then swooped in with their army of drug detailers to save the day (“Look what we have for you! Safe, non-addictive OxyContin! We can help you meet that pesky TJC and CMS standard! We are your heroes!”).

To put this in historical perspective, before OxyContin, the Sackler family has had a long and strong history of aggressive marketing (Podolsky, Herzberg, & Greene, 2019). In the 1950s, Arthur Sackler, a psychiatrist, worked for a public relations firm. When Pfizer began producing antibiotics (they’d only been known as a chemical firm before this) they needed a new marketing approach. Enter Dr. Sackler with his army of salesmen, deployed to physicians’ offices. These aggressive tactics led, in part, to overprescribing of antibiotics and its long-term effects of creating multiple drug-resistant organisms which we are seeing now. They also caught the attention of Senator Estes Kefauver (D-TN) who led the investigation of what he and his staffers felt “looked like components of a Mafia investigation” (Podolsky et al., 2019, p. 1787). Although Arthur Sackler is dead, Purdue Pharma, which is controlled by the Sackler family, has continued his legacy of predatory practices (Podolsky et al., 2019).

and Order
Millions of patients became addicted to OxyContin and the drug soon became a street drug, thanks to unscrupulous prescribers and drug distributors—all regulated by the DEA. Williamson, a tiny West Virginia town (population 2,900) with two pharmacies, received over 20.8 million pain pills between 2006 and 2016 (Eyre, 2018). In 2008, one of the same drug wholesalers, Miami-Luken, shipped enough drugs to Kermit, West Virginia (population 400) “to provide 5,624 prescription pain pills for every man, woman and child in the town” (Eyre, 2018, para. 9). The obvious question is where did these drugs go? The answer: the illicit black market for a nice profit. The manufacturers, the distributors, the drug stores, the pharmacists, and the physicians all contributed to West Virginia’s dubious distinction of having the highest drug overdose rate in the nation (Eyre, 2018).

As with Al Capone and his gang of criminals, the wheels of justice have been slow to turn on this epidemic, but the law is catching up to the greedy, suit-wearing, prescription drug dealers and their enablers. In April 2019, Laurence Doud III, the CEO of Rochester Drug Co-Operative, was “indicted for narcotics conspiracy and conspiracy to defraud the DEA” (“First major,” 2019, para. 3). Among other evidence, the trial revealed the CEO instructed employees to disregard internal compliance policies regarding the control and distribution of OxyContin and knew the drug was being diverted to illegal distribution channels (i.e., the streets), all to increase his executive compensation (“First major,” 2019).

In May 2019, a jury found five executives of Insys Therapeutics guilty of “federal racketeering charges for bribing doctors to prescribe Subsys, a nasal spray version of the highly addictive synthetic opioid fentanyl to people who didn’t need it. They were also convicted of defrauding Medicare and private insurance” (Drash, 2019b, para. 1). Included in the evidence for the jury were testimonies about dinners for physicians for thousands of dollars, extravagant parties, sexual favors, and a rap video in which the executives danced and sang about getting doctors to prescribe the drug to patients who don’t need it (Drash, 2019c).

As of this writing, there are over 1,600 lawsuits, including cities, counties, tribes, and states, against Purdue Pharma (“Family behind OxyContin,” 2019; Joseph, 2019). The APS, a supposedly independent organization which led the drumbeat of “Pain as the 5th Vital Sign” is also being targeted by these lawsuits because, among other reasons, they took over $1 million from Purdue Pharma. The lawsuits and subpoenas have driven APS to file for bankruptcy and close down (McGreal, 2019). In 2007, Purdue Pharma pleaded guilty to “understating the risk of addiction to OxyContin, including failing to alert doctors that it was a stronger painkiller than morphine, and agreed to pay $600 million in fines and penalties” (Armstrong, 2019, para. 4). ProPublica obtained court records of emails detailing the Sackler family’s role in the aggressive, duplicitous marketing of a highly addictive opioid. As majority members of Purdue Pharma’s board, they are ultimately responsible for their company’s actions. It remains to be seen if criminal charges will be brought against any of them. However, reports indicate the eight Sackler family members involved in the litigation are at odds with each other on how to address former Purdue President Richard Sackler’s emails maligning patients addicted to OxyContin (Spector & DiNapoli, 2019). The indictments of Laurence Doud, III and the Insys executives send a chilling message to all modern day drug lords: you play, you pay.

Addressing the Opioid Epidemic
Thanks to the predatory practices of drug companies plus illegal production of opiates and derivatives, such as fentanyl, the opioid epidemic has hit almost every urban, suburban, and rural family in the U.S. The CDC (2018c) reported “over 700,000 people have died from a drug overdose since 1999. Over two-thirds of the 70,200 drug overdose deaths in 2017 involved an opioid. On average, 130 Americans die every day from an opioid overdose” (para. 1). As you can see from TABLE 17-3, more males die from opioid overdoses than females.

The Comprehensive Addiction and Recovery Act of 2016 authorized the Attorney General and Secretary of DHHS to award grants to address the prescription opioid abuse and heroin use crisis, among other purposes. In 2017, the opioid “crisis” moved to opioid “epidemic” and “national emergency” (Gostin, Hodge, & Noe, 2017). Congress created the SUPPORT for Patients and Communities Act of 2018 to address the opioid epidemic/emergency. The act includes “provisions to strengthen the behavioral health workforce through increasing addiction medicine education; standardize the delivery of addiction medicine; expand access to high-quality, evidence-based care; and cover addiction medicine in a way that facilitates the delivery of coordinated and comprehensive treatment” (SAMHSA, 2019b, para. 2). We are very early in the planning and implementation phases of the projects and programs to address this national emergency. As of this writing, there have been no quick fixes; we are still waiting to see the impact of this law, its task force on pain management, and its treatment and recovery plans. All of the players who were complicit in creating this crisis must work together to put an end to it. For the law to work, the programs and plans must include decriminalizing and destigmatizing those who suffer with SUDs, OUDs, and mental illness. Otherwise, we will continue to have an underclass of citizens who feel they must hide in the shadows to avoid arrest. As a health care manager, you must put yourself in the shoes of those suffering from SUDs, OUDs, and mental illness. Would you prefer to be demonized and told that you’ve made a bad moral choice? Or would you prefer to be treated with compassion and the recognition that addiction is a cunning, baffling, powerful, and relapsing disease? You can make a difference in this crisis by making a choice to set aside your biases and preconceived notions of people who suffer from addiction and come to your health care organization for help.

The Legal Drugs: Tobacco and Alcohol
Tobacco
Currently, all eyes are on the opioid epidemic. Media headlines and news commentators scream about deaths from overdoses. “Our children/sisters/brothers/mothers/fathers are dying! How did we get here? What are we doing about it?” Deaths from any preventable cause, whether from vaccine-preventable diseases, car accidents, or violence, are tragedies on personal, local, state, and federal levels. However, contrary to the hyped up headlines, opioid deaths are not the biggest source of deaths in the U.S. The greatest hazard to our health is not from illegal drugs. The greatest threat to you, your family, your employees, and your patients is a legal one: tobacco.

According to the CDC (2018d), each year “Smoking-related illness in the United States costs more than $300 billion…with nearly $170 billion for direct medical care for adults, more than $156 billion in lost productivity, and $5.6 billion in lost productivity due to secondhand smoke exposure” (para. 18). To put this in dollars closer to home, each smoking employee costs an employer approximately $6,000 per year (Berman, Crane, Seiber, & Munur, 2014).

The death toll from tobacco adds to these costs. Each year in the U.S., almost half a million people die from the harmful effect of tobacco. As you can see from TABLE 17-4, Annual Cigarette Smoking-Related Mortality in the U.S., 2005–2009, tobacco causes more than just one disease. Tobacco is incontrovertibly and causally linked to:

■   Cancer: lung cancer and cancers of the lip, pharynx, oral cavity, esophagus, stomach, pancreas, larynx, cervix, uterus (women), kidney and renal pelvis, bladder, liver, colon, and rectum; also, acute myeloid leukemia;
■   Cardiovascular and metabolic diseases: coronary heart disease, rheumatic heart disease, pulmonary heart disease, and other forms of heart disease PLUS diabetes, cerebrovascular diseases, atherosclerosis, aortic aneurysm, and other arterial diseases;
■   Respiratory diseases: pneumonia, influenza, tuberculous, chronic obstructive pulmonary disease, emphysema, bronchitis, and chronic airways obstruction;
■   Perinatal deaths: stillbirths, prenatal conditions, and sudden infant death syndrome;
■   Residential fires with deaths from smoke inhalation and burns; and,
■   Secondhand smoke which can cause any of the above, including lung cancer in non-smokers.

The good news about smoking cigarettes, or any use of tobacco and nicotine products (chew, bidis, vaping, e-cigarettes, etc.) is that if a person quits using them, their chances of avoiding the harmful effects are averted. The bad news is that adolescents believe vaping and e-cigarettes have no harmful effects. The fact is, early nicotine use sets young people up to become addicted to other drugs (NIDA, 2014). The sooner someone quits the better. Some people need to go cold turkey (quit altogether), others may need nicotine gum or patches, and still others may need drugs, such as CHANTIX® (varenicline), that allow them to quit gradually as cravings recede. Prochaska and Diclemente’s (1983) ground-breaking work on the stages of behavior change in smoking cessation continues to provide a model for other substance use disorder cessation programs, including alcohol, opiates, and other drugs. Health care managers and organizations have an important role to play in keeping employees and patients safe from the harmful effects of tobacco. Most hospitals and health care organizations have smoke-free buildings and campuses. Some employers offer discounted health insurance rates for non-smokers and have health coaches and wellness mentors to assist employees in quitting. In addition to encouraging employees not to smoke, you can be a role model for others and not use tobacco and other nicotine containing products yourself.

Alcohol
Had the WCTU employed a disease-based framework for their efforts, their name might not be associated with ax-wielding, rock-throwing, window-smashing fanatics. However, because they approached the problem of rampant alcoholism in the 1900s with Puritanical beliefs and the breathless zeal of crusaders, their biases and assumptions got in the way of their critical thinking abilities (see the chapter in this text on organizational behavior and management thinking for more on these topics). Much research has been devoted to the etiology and life cycle associated with alcoholism. Twin studies and other genetic research have revealed that some people are genetically pre-disposed to become alcoholics (Agrawal & Lynskey, 2008; Verhulst, Neale, & Kendler, 2014). However, not all people who have this predisposition become alcoholics. Why? Because the milieu, i.e., the environment in which they are raised and live, does not induce or enable them to become alcoholics. An oft-used analogy for this nature versus nurture argument goes like this: genetics (nature) loads the gun; environment (nurture) pulls the trigger. If someone is aware that they have a first-degree relative (father, mother, sister, brother) who suffers from the disease of alcoholism, then they may make a conscious choice to monitor their alcohol intake or even abstain to avoid succumbing to the disease. This does not mean this approach will always be successful, but this is the point at which they have the opportunity to put their thumb on the scale in favor of health.

TABLE 17-5 demonstrates the numbers of lives lost due to the harmful effects of alcohol in the U.S. between 2006 and 2010. As health care managers, it is incumbent upon you to refer any employees who come to you with this concern to your Employee Assistance Program (EAP), a health services organization–sponsored program made available to employees, and often times their dependents, to assist with personal or family problems that affect the employee’s job performance. EAPs have hotlines to call and can provide confidential assistance with finding help for a wide variety of psychosocial matters from domestic violence to alcohol and drug addiction. Nota bene: If someone suffers from the disease of alcoholism and is physically dependent, i.e., cannot function without a drink, and if they want to quit, they must seek medical help. Unlike tobacco or opiates, sudden withdrawal from alcohol can kill. It is absolutely critical to seek a health care provider for assessment of the degree of addiction and the right setting for a detox before entering a rehabilitation program. Not all rehabilitation facilities have detox units with hospital beds, physicians, and nurses who are qualified to support an alcoholic through withdrawal. This is why it is imperative to seek out a qualified addictions medicine health care professional to guide the individual to the best placement.

Emergency and Disaster Management

Emergencies and disasters are a part of living on Earth and our world’s population is growing. As the world grows, more people are moving from rural areas to urban areas and this trend is expected to continue for the foreseeable future. This means when emergencies and disasters hit the more densely populated urban areas, it will affect more people. What does this mean for the health care manager? It means that it is important to know what emergencies and disasters you will likely face, how these will affect your organization, and what tools and resources you have to deal with these growing concerns.

Included within the category of emergencies are widespread trauma (building collapsing, mass shooting), chemical spills or leaks, and diseases such as Ebola. Disasters include, but are not limited to, hurricanes, tornados, earthquakes, fires, floods, and heat waves. Although the range of these is quite large, the effect on the health care manager is similar. To recap, the population is growing, there are more emergencies and disasters, these hit urban areas harder than rural, and most health care managers will deal with these at some point in their careers, so it is best to be prepared. Since we cannot cover all of these in this section, we will focus on heat disasters, since they are the most prevalent, costly, and deadly.

Heat Disasters
Heat kills more than all other natural disasters, it’s more costly, and it is on the rise (Drugmand, 2018; Environmental Protection Agency [EPA], 2016; National Weather Service, 2019a; World Meteorological Society [WMO], 2018a). Look at FIGURE 17-6 to see the proportion of deaths in the U.S. due to heat versus hurricanes, tornados, and floods. Urban area heat disasters have the added complexity of urban heat island effect which means temperatures rise even higher due to the concrete in the city (EPA, 2019). The number of deaths directly attributed to “heat” is lower than the actual number caused by heat, and this is largely due to the definition of a heat wave and what constitutes a heat-related death. There is no formal definition of a heat wave, but several ambiguous definitions exist (Rafferty, 2018). One simple definition of a heat wave is an “extended period of unusually high temperatures with significant societal and environmental impacts” (Raei, Nikoo, AghaKouchack, & Mazdiyasni, 2018, para. 1). The WMO (2018) spent three years gathering information on defining a heat wave and published:

A period of marked unusual hot weather (maximum, minimum and daily average temperature) over a region persisting at least three consecutive days during the warm period of the year based on local (station-based) climatological conditions, with thermal conditions recorded above given thresholds (p. 4).
Almost all medical conditions are made worse by heat, and when you examine the most at-risk populations for heat-related disasters, it becomes clearer why the number of heat-related deaths is underestimated. Most vulnerable populations include those over 65, those with conditions such as heart disease and diabetes, infants below the age of 4, the socially isolated, and those who have multiple complicating medical and mental health issues (CDC, 2017b; O’Lenick et al., 2019). To illustrate, if someone has a heart condition and they live on the third floor of an apartment complex and a heat wave begins, their heart condition may be complicated, and there would be no one to check on them for several days. If they passed during this time, their death would likely be characterized as heart disease related rather than heat related. In this case, the heart condition was made worse by the heat, and it is difficult to determine whether the death would be due to the heart condition or a heat disaster. This matters since resources allocated during disasters are largely distributed based on decision trees; if definitions are not clear, then it has a ripple effect on many decisions at multiple levels.

Keeping what we have covered in mind, let’s take a look at some heat disasters from the last 30 years. In Chicago, in the summer of 1995, a conservative estimate of 500 people (realistic estimate at 800) died in five days (Semenza et al., 1996). In August 2003, a heat wave hit Europe and caused a death toll in of excess of 70,000 (Robine et al., 2008). In the summer of 2010, 55,000 excess deaths were reported in Russia as a result of a heat wave (Barriopedro, Fischer, Luterbacher, Trigo, & Garcia-Herrera, 2011). These heat disasters are no small matter and affect a great many organizations and people.

Health care managers face a unique challenge as more Americans suffer from chronic conditions, mental illness, and isolation, which grows as an epidemic (O’Lenik et al., 2019; Semenza et al., 1996). Whether emergencies or natural disasters are causing immediate damage in inpatient settings, delayed complications as people head to hospitals for treatment, or prolonged chaos through their aftermath, dealing with these is quite the challenge. As we continue our focus on the deadliest type of disaster, heat, let’s consider the amount of resources available for dealing with this disaster compared to others. If you want to investigate information on preparing for hurricanes, tornados, and floods, there is wealth of information available in many places starting with the web. You may even have a bank of knowledge about these in your own mind. In addition, the majority of health organizations in urban areas affected by these on a regular basis have a realistic emergency plan, response, recovery, and mitigation strategies.

Now, what happens if you look for these same resources related to heat waves? These resources barely exist, and those that do exist are not very realistic. Most heat disaster plans ask people to move to the nearest air conditioned public space. And what about the great number of people who work outdoors in urban heat islands (Riley, Wilhalme, Delp, & Eisenman, 2018)? Research shows that working air conditioning is the strongest defense against heat-related deaths (Naughton et al., 2002). This might be okay if we were guaranteed that our health organizations would retain electricity.

But, let us put together what we have covered so far to get an accurate picture of where a health care manager begins to deal with a more complicated issue. The number of most natural disasters is on the rise, and power outages are a side effect of almost all of these. Once the power is out, heat becomes a secondary disaster, and most contingency plans are made obsolete (this is because the majority of contingency plans for heat-related disasters rely on electricity). Think about the hurricanes such as Katrina in 2005, New Orleans; Harvey in 2018, Houston; Maria, in 2017, Puerto Rico; or the tornado in Joplin, 2011. Many people went without power for weeks and months and heat disasters became secondary to the primary disasters.

So, what can you do as a health care manager to help prepare your organization and yourself throughout your career? Organizationally, the first step is to have your front line providers trained in the stages of heat illness: heat cramps, health exhaustion, and heat stroke. When people are exposed to something dangerous every day and they are not harmed, they tend to lose the fear of the something happening to them. This is especially true of heat. Without proper training, medical providers may not be adequately aware of the danger posed by heat disasters. This is also compounded by the general public’s minimizing of heat as a disaster, especially when compared to other disasters such as hurricanes, tornados, and flooding. Remembering to stay alert to the danger of all emergencies and disasters is important, especially those that may seem easier to control like heat.

Being able to triage these three stages of heat illness is critical when assigning the limited resources you will have to deal with this problem when it occurs (CDC, 2017c). TABLE 17-6 lists symptoms by the three heat-related illness stages. The triage methods for heat disasters are the same whether you are in the general population, the health industry, or a health care delivery organization (inpatient and outpatient). As a manager, it is your job to ensure your organization has the training in place to know these three stages, how to triage based on vulnerable populations, and how to provide available treatment options.

New research showcases that the lack of a consistent definition of a heat wave still poses the largest obstacle to developing early alert systems and confirms the most vulnerable populations remain the same as they have been for the last 30 years (Yang et al., 2019). One important new vulnerable population is people with cognitive impairment, defined as “the stage between the expected cognitive decline of normal aging and the more serious decline of dementia. It can involve problems with memory, language, thinking and judgment that are greater than normal age-related changes” (Mayo Clinic, 2018, para. 1). It remains to be seen how this new vulnerable population will be affected. In addition to these findings, research confirms that cities in northern, typically cooler locations suffer from heat-related disasters more than southern, typically warmer, cities (Yang et al., 2019). This is because residents in normally hotter climates expect heat and are more prepared for its effects.

Aside from training and planning at an organizational level, there are also population level strategies to implement. Chicago learned from the 1995 heat disaster and 20 years later, they can stand as a model to others for how to deal with these types of disasters. Their Office of Emergency Management pooled representatives from several important sectors such as health care systems, emergency responders, public health, city and county resources, and traffic management in one central location to increase and speed up communication (Rubin & Gorner, 2015). Several other major cities have adopted this strategy and put in the extra work of coordinating and collaborating with multiple governmental and private entities to ensure they are prepared for what is sure to come in the future. Another lesson learned in Chicago is how to use data to recognize patterns more quickly and to triage resources to areas of the city in the highest need based on a population health approach. For example, a city may use geographical information systems to identify areas where people suffer from higher levels of mental health and isolation issues. Once identified, city planning and census data would help to identify specific buildings where vulnerable populations might need help first. Resources, such as cooling buses, may be dispatched to those areas to provide relief after emergency responders have triaged residents. Health care managers of pre-selected health care organizations would be ready for the intake of these residents and/or treatment on the cooling buses. Physicians in Chicago learned valuable lessons about how these types of systems can be deployed for multiple types of disasters, not only heat related disasters (Rubin & Gorner, 2015).

There are some general principles to keep in mind as you walk through an emergency or a disaster as a health care manager. People only remember what happened the last time they had a particular type of disaster. For example, if the last hurricane was not that bad, then everyone will have a more difficult time getting people to prepare for the next one coming, no matter how serious the hurricane and the data supporting the claim. A helpful tip to remember is that most people only experience heat-related injuries when they are young, and they compare their next experience as an adult to the last time it happened to them when they were young and underestimate the risks. How would heat cramps in a youth compare to heat exhaustion in a middle aged person or a heat stroke in an elderly person? With this in mind, how might this affect preparations for a heat disaster? It will likely make it more difficult to act at the organizational level alone.

This explains why the cycle for emergency and disaster management referenced in FIGURE 17-7 has three levels to go with the four phases. The three levels are the (1) consumer level, which would be the client the health organization is serving; (2) the organization itself; and (3) the larger population level, which would be your community, city, and county. The four phases are (1) mitigation, which is to minimize the opportunity for damage from an emergency or disaster; (2) preparedness, which is preparing for an emergency or disaster; (3) response, which is responding to an emergency or disaster; and (4) recovering from an emergency or disaster.

The levels and phases are not mutually exclusive of one another and have much overlap. This figure is meant to act as a general guide to conceptualizing what the big picture is related to emergency and disaster management.

Depending on your type of health organization, it may make the most sense to educate your consumer about the first and second phases of mitigation and preparedness rather than rely on the organization or population level for resources. This might be educating your patients in a primary care health clinic, or residents in a senior living community, with educational information like Table 17-6 earlier in the chapter. If you are working within a midsize organization, you may not have the resources or authority to create or maintain emergency disaster plans. In this case, it might be a good idea to coordinate with population level entities in your community, city, or county to fold your organization into their larger strategies. When working in a large health care system, chances are someone is tasked with emergency and disaster planning already, and it may only be a matter of taking advantage of what is available.

In the third and fourth phases of the cycle, there will be some type of response to, and recovery from, the emergency or disaster no matter the type of health organization. Health care managers that know what organization and population level resources are available will fare better than those who do not. One major population level resource that can help with all phases of emergency and disasters is called Community Emergency Response Teams (CERT) (Ready.gov, n.d.). Knowing what your community has in terms of CERT can be a real asset to your health organization, especially when dealing with a heat disaster since they can help act as extensions of your organization. In a heat disaster, there will be fewer natural barriers preventing logistics like transportation than there would be in hurricanes, tornados, or floods, and there may be more time to get things accomplished to avert further damage. CERT is a grassroots effort organized by the Federal Emergency Management Agency (FEMA) that has been around since 1985. There are a wealth of training and materials available through CERT that cover both the emergency and disaster management as well as basic medical operations and disaster simulations.

Another great resource offered to health care managers is the FEMA Emergency Institute at https://training.fema.gov/. The Institute offers over 200 emergency and disaster management courses for free to help organizations no matter the phase of the process in which they are currently operating. At a minimum, it is highly recommended that all health care managers complete IS-100.C: Introduction to the Incident Command System (ICS). This two-hour course provides an overview of a command system that can be put in place if an emergency or disaster occurs and gives a common understanding so that in the case of an emergency or disaster your organization would be able to communicate effectively with national levels of government (FEMA, 2018).

The important thing to remember is to have realistic plans for yourself, your organization, and your larger community (der Heide, 2006). Work with facilities planning in your organization for the logistics of emergency and disaster situations such as power outages and generators or communication backup for when phone systems go down, to coordinating plans for how you would evacuate patients or residents for the long term. Better to have those conversations ahead of time rather than try to figure them out in the midst of a crisis situation. Take the time to build relationships with your population level entities like your city and county offices. Although we focused heavily on heat disasters since they are the deadliest, these principles are the same for dealing with all emergency and disaster scenarios. The likelihood of you encountering a crisis situation is great, so take the time to utilize resources and be prepared.

Opportunities for Research on Special Topics and Emerging Issues in Health Care Management

This chapter has brought some of the most current topics impacting health care management to your attention. Opportunities for in-depth research on these emerging issues exist in a variety of venues, particularly in those areas where data are sparse due to the early identification of the issue, such as re-emerging outbreaks of vaccine-preventable diseases and heat-related disasters, or in those areas that are illicit, illegal, or embarrassing, such as violence in health care, mental illness, and substance use disorders. Many of the resources we used and noted in writing this chapter also include extensive research holdings and data sets that are available to students and academic researchers. In particular, the CDC, NIDA, National Institute of Justice, and other federal agencies have data sets that are available to be downloaded in user friendly formats. If you are curious and want to learn more about the topics we addressed, here is a list to get you started.

■   Bureau of Alcohol, Tobacco, Firearms, and Explosives (ATF);
■   Bureau of Justice (BJS);
■   Centers for Disease Control and Prevention (CDC);
■   Drug Enforcement Agency (DEA);
■   Environmental Protection Agency (EPA);
■   Federal Emergency Management Agency (FEMA);
■   Library of Congress;
■   National Archives;
■   National Institute of Justice (NIJ);
■   National Institute on Drug Abuse (NIDA);
■   National Institutes of Health (NIH);
■   Occupational Safety and Health Administration (OSHA);
■   National Center for Victims of Crime;
■   National Committee for Quality Assurance (NCQA);
■   National Weather Service (NWS);
■   Substance Abuse and Mental Health Services Administration (SAMHSA);
■   The Joint Commission (TJC);
■   United Nations Office on Drugs and Crime (UNODC);
■   U.S. Department of Homeland Security (DHS);
■   U.S. Department of Veterans Affairs (VA);
■   U.S. National Library of Medicine (NLM);
■   World Health Organization (WHO); and,
■   World Meteorological Organization (WMO).