Active shooter drills are common for hospitals, particularly among academic medical centers, industry observers and associations said. But hospitals have a wide latitude in deciding what types of hazards are most relevant to their facilities, experts said.
"In principle, hospitals should consider 'active shooter' as one of the relevant hazards to plan and train for as part of 'all hazards' preparedness. But in practice, hospitals have broad discretion," Glen Mays, a professor of health system management and policy at the University of Colorado Anschutz, said in an email. "Academic medical centers are especially tuned into active shooter risks because of their educational mission alongside their clinical care mission."
There are two national requirements regarding hospital emergency preparedness: the federal CMS emergency preparedness rule and the Joint Commission accreditation mandate. Both require hospitals to have "all hazards" emergency response plans and train staff at least annually. The Joint Commission listed active shooter preparation as a requirement in its June 2021 update.
Generally, staff review active shooter response protocols for hospital security personnel, contacting law enforcement, evacuation, shelter-in-place and clinical guidelines for addressing mass casualty events. Training typically includes active-shooter drills and exercises with law enforcement personnel.
Northwell, for instance, reviewed the Tulsa case with its staff, running through what preventative protocols it has in place, what needs to be adjusted and how they would respond.
At least once a year, the health system performs active shooter drills. It offers each of Northwell's 80,000 employees training on active shooter situations, de-escalation and "stop the bleeding" processes. Armed police officers and security guards are stationed at Northwell hospitals, Strauss said.
Northwell created a "safe place initiative group," which gathers employees from its legal department, quality, patient experience and others to discuss how they improve workforce safety and the patient experience. It implemented a more thorough visitor access control system to better screen visitors and is considering a concealed weapon detection system, Strauss said.
"Here at Northwell, we have been very fortunate to have buy-in from senior leadership on security protocol," he said. "If you don't have buy-in from senior leadership, you don't have anything."
The 21-hospital Cleveland Clinic has several active shooter training programs throughout the year, a spokesperson said.
Gun violence preparedness varies by hospital. Some hospitals have armed guards and weapon detection systems. Health systems' emergency preparedness levels have remained relatively stagnant in recent years as they focused on the COVID-19 pandemic.
The national average score remained at 6.8 out of 10 in 2020, unchanged from the prior year, according to the National Health Security Preparedness Index. At the current pace, most states will require eight years to reach health security levels currently found in the best-prepared states.
Communities with stronger preparedness measures experienced significantly lower mortality risks related to the COVID-19 pandemic, according to the report, which analyzes dozens of different measures like the number of available paramedics and medical volunteers, the degree of community engagement, the level of information management and infrastructure stability.
Several proposed bills and litigation aim to bolster health systems' safety protocols and limit the circulation of guns.
"As we have said repeatedly since declaring gun violence a public health crisis in 2016, gun violence is out of control in the United States, and, without real-world, common-sense federal actions, it will not abate," Dr. Gerald Harmon, president of the American Medical Association, said in a statement.
The U.S. House of Representatives recently passed a bill that would require healthcare employers to implement workplace violence prevention plans that would protect workers and other personnel from shootings and other events.
The Protecting Our Kids Act was recently introduced in the House Judiciary Committee. It would ban the sale of semi-automatic guns to anyone under 21 years old, among other provisions.
"Tulsa's terror on Wednesday should remind us all of both the accelerating incidents of violence in healthcare settings and the urgency of legislative action to safeguard our caregivers, other healthcare staff, and every patient or family member in those facilities," Jean Ross, president of National Nurses United, said in a statement.
But it's uncertain whether Congress or state legislators will pass related laws or whether lawsuits against health systems will hold up in court.
A widow of a nursing assistant who was shot and killed at Thomas Jefferson University Hospital last year sued Jefferson Health, which allegedly had lax safety measures, according to the lawsuit filed Tuesday in Philadelphia Common Pleas Court. Jefferson Health declined to comment.
In another case, a woman was shot three times at a hospital in Florida and sued the facility for alleged security breaches. The court ruled that the hospital's contract with the security company only required the guards to protect the hospital and its employees.
Standards of workplace safety and compliance are relatively subjective, hinging on the specific case and facility, said Mark Silberman, chair of the white collar, government investigations and regulatory practice compliance group at the law firm Benesch.
"Unless we are willing to address the larger issues that allow these things to happen, we can't put all the onus on healthcare facilities without fundamentally changing the role that we need them to play," he said.
Mari Devereaux contributed to this report.
