The media has been chock full of news about sexual harassment and related issues creating a hostile work environment. Do not think that this news escapes either CMS (state) or TJC surveyors’ attention.

We know from experience that issues in the news influence surveyors’ sensitivity and alertness to related Conditions of Participation and standards enforcement.

The recent headlines referencing potential issues of nondisclosure at Cleveland Clinic focused on alleged patient assault/rape will likely increase attention during surveys to practitioner appointment and renewal to the medical staff, and to the peer review process. Also, expect attention to Human Resources issues on hostile work environments and the impact on communication and patient/staff safety.

Sadly, that’s far from the only case currently in the news:

UConn Health System found liable for clinician’s sexual harassment

Arizona State Hospital top doctor has history of sexual misconduct, harassment

Additionally, Becker’s Hospital Review recently reported that at least 3,085 hospital employees filed sexual harassment claims between 1995 and 2016, while 12% of healthcare practices lack a sexual harassment policy.

Protecting Patients and Staff

CMS Tag A-0145 establishes patients’ right to protection in healthcare environments:

  • 482.13(c)(3) – The patient has the right to be free from all forms of abuse or harassment.

Regarding staff protection, OSHA provides guidelines for preventing workplace violence.

Additionally, the Joint Commission has issued numerous Sentinel Event Alerts dedicated to establishing a culture of safety and preventing violence in the healthcare setting:

TJC has also developed a portal intended to share informative and useful resources with the field regarding preventing workplace violence in healthcare settings.

Promoting a Culture of Patient and Staff Safety

Compass is aware of hospitals receiving increased scrutiny by CMS (State) for allegations by patients of sexual harassment. Many organizations are caught off guard as they have not developed policies/procedures to address how to respond to staff’s complaints of sexual harassment or how to address a patient’s allegation of sexual assault while an inpatient. All too often, leaders have received little to no training to provide guidance in helping them to respond in a sensitive manner that promotes a culture of patient safety and staff safety, nor have they provided training to staff on ways to limit their potential liability of being accused of sexually harassing a staff member or a patient.


Compass can help your organization identify opportunities to improve your culture of safety. To ensure that your organization doesn’t receive unwanted scrutiny for failure to create a work environment conducive to patient safety, contact Kate Fenner, RN, PhD, Managing Director at (513) 241.0142, via email, or via our contact form for a confidential discussion of your concerns and to schedule an assessment of safe work practices in your organization.

Image credit: iStock / Thinkstock

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