Chris Van Gorder, president and CEO of California-based Scripps Health, is no stranger to hospital-based violence.

In his time spent in hospital security, he’s been stabbed and had a patient throw urine on him, among other incidents. When his hospital system began experiencing a post-pandemic uptick in violence to the tune of 31% in 2023 alone, Van Gorder knew he had to act.

Scripps isn’t alone in the growing incidents of hospital-based violence. Nationwide, cases have increased, too, making healthcare the industry with the highest incidence rates for workplace violence of any private industry. Physicians and healthcare workers face everything from verbal aggression to physical attacks on a daily basis. 

“There’s been an incredible rise in frontline healthcare worker violence,” said James “Scott” Gee, deputy national advisor for cybersecurity and risk at the American Hospital Association (AHA). “We believe a number of factors have contributed to the trend, including an overall decline in civility, a loss of respect for people in positions of authority, financial pressure on patients, and an increase in addiction and emotional stress.”

Combined, the factors have led to a boiling-over point, and the impacts are far-reaching. They include disruption of care, low employee morale, and related workers’ compensation payouts of $19 billion, according to the AHA.

For these reasons, the AHA recently partnered with the Federal Bureau of Investigation (FBI)’s Behavioral Analysis Unit-1 to create resources designed to help hospitals mitigate violence through Behavioral Threat Assessment and Management (BTAM) practices. While not a one-size-fits-all approach, it provides a multidisciplinary framework that hospitals can implement to bring the threat level down. It’s a model hospitals like Scripps are using, and the results are promising.

Getting Ahead of Violence

In reaching out to the FBI, the AHA was able to tap into 17 of the organization’s subject matter experts to create the guidance. They included mental health experts, researchers, medical professionals, and law enforcement representatives. Together, they created templates, models, and implementation references to support hospitals in their efforts to identify and mitigate potential threats before they develop into acts of violence.

Gee and John Riggi, AHA’s national advisor for cybersecurity and risk, led the efforts for the AHA. Both bring decades of experience to their roles in the FBI and the Secret Service. Both say that, while impossible to predict every incidence of violence, attempts at prevention are critical.

“It’s complicated and time-consuming, but if you can prevent violence, it improves safety, retention, and patient care,” said Gee. “We’d rather prevent crime than respond to it.”

For that reason, the AHA/FBI project makes threat identification the first step in violence prevention. Whether threats begin online, in person, or elsewhere, having the ability to identify a threat is critical. 

“Training nurses and other frontline workers, as well as security staff, in threat identification and then de-escalation is key,” said Gee. “There are a number of things you can do in this regard.”

Often, say Gee and Riggi, when you look back at hospital violence events, there were plenty of signs. “Look for agitation and grievance points,” said Gee. “If someone shows up at a facility to express their grievance, that’s a clear indication that the situation could escalate.”

The BTAM guide recommends training staff to identify threat behaviors from patients, family, visitors, and even coworkers. While some of these threats may happen in a silo, they often overlap. A patient who feels he’s not receiving adequate treatment may express this grievance to a family member, who may in turn become agitated and threaten violence, for instance.

Effective violence prevention requires a multidisciplinary team approach with members both inside and outside the hospital setting. This involves education at the executive and leadership level as well as throughout the hospital setting.

A hospital-based team might include behavioral health, security, legal services, patient relations, and risk management. Outside partnerships may include local law enforcement and FBI field offices.

While fears of Health Insurance Portability and Accountability Act of 1996 violations often keep hospital leaders from reaching out to law enforcement, there is an exception to that when law enforcement can assist in preventing or lessening a serious and imminent threat. 

A Model of Success

The Scripps Health program is emblematic of how hospitals can find success with a multidisciplinary approach. In the fall of 2024, Scripps hired a retired FBI special agent to lead its security efforts. It also trained physicians and staff in de-escalation, implemented high-tech metal detection, limited building access, and created a fast-response behavioral health team.

Van Gorder also reached out in partnership with San Diego’s chiefs of police, sheriffs, and the district attorney to form the San Diego County Hospital Workplace Violence Committee. 

“We believed we needed to take this on as a community, not just a hospital,” said Van Gorder. “We meet every couple of months to review cases, discuss education and training, and identify new approaches to response and prevention.” 

The AHA/FBI guidance recommends that all parties receive periodic information about potential behaviors of concern. Hospital leaders should also provide staff with multiple reminders using a variety of methods, including face-to-face training, website reminders, email, and more. The guidance also emphasizes the importance of reporting concerning behaviors.

“Most targeted acts of violence will arise from a grievance, whether it appears logical or not,” said Gee. “Reporting these behaviors can lead to de-escalation and prevention.” 

In that spirit, Scripps also holds regular in-person forums with front-line healthcare workers to address concerns, with law enforcement in attendance. Within the hospital system, leadership also established “Code BURT,” the behavioral urgent response team. “If a staff member issues a Code BURT because a patient or family member is escalating into a disturbance, they can receive immediate behavioral health assistance,” said Van Gorder.

As a result of all the violence prevention efforts, Scripps saw 70% more BURT calls than security response calls in 2024. The number of reported assaults also dropped, and the number of threat incidents dropped by 31% in 2024, followed by another 15% drop at the end of 2025, across all five Scripps hospitals.

“We’re never going to eliminate all threats and violence, but any one reduction is a win,” said Van Gorder. “It keeps the doctors and nurses at work, reduces trauma, and improves the quality of patient care.”

While prevention is the number one goal, and most violent incidents can draw a line to prior agitation and grievances, there are times when violence is unexpected and opportunistic. An agitated patient might grab a nearby chair as a weapon, for example. This is where healthcare workers often get into trouble.

“Law enforcement is trained to assess safety and proceed from there,” said Van Gorder. “Healthcare workers run right into an escalating situation because they are concerned with helping.”

For that reason, the FBI’s guidance includes recommendations to train healthcare workers to slow down and assess before moving toward the agitated patient or family member. As Van Gorder puts it, “Behavior emergencies require security.” 

If one healthcare worker gets hurt, another is likely to follow right behind them, leading to more injured staff, trauma, and lost healthcare-giving opportunities. 

While the FBI/AHA trainings are fresh out of the gates, the 5000 hospital systems in the AHA network have positively received them, according to Gee. 

“Many hospitals are already implementing some forms of the recommendations, and some may overlap,” he said. “But we’re creating a tremendous amount of awareness and offering a framework and demonstrating a great public/private partnership to help our hospitals.”