Hospital Signage Outlining Behavioral Expectations in a Health Care Environment

Hospitals increasingly look for ways to deter patients and visitors from engaging in aggressive or violent behavior toward staff. When considering posting signs or other notices referencing policies against violence, hospitals must consider whether they could be interpreted to deter patients from coming to the emergency department. The Centers for Medicare & Medicaid Services previously condemned signs it determined could discourage patients from seeking emergency care, in violation of the Emergency Medical Treatment and Labor Act. MHA recommends hospitals use positive messages that encourage a healing environment instead of focusing on aberrant behavior by patients and visitors.

In 2013, CMS strongly discouraged the use of pain posters to address inappropriate opioid-seeking behavior. A guidance letter issued by the agency stated that the suggested (and any similar) language “might be considered to be coercive or intimidating to patients who present to the ED with painful medical conditions, thereby violating both the language and the intent of the EMTALA statute and regulations.” When questioned further, the author explained the sign “appears designed to indiscriminately discourage any individual seeking treatment for pain from remaining in the ED for a medical screening examination or from coming to that ED in the future.”¹

Similar to signs deterring drug-seeking behavior, MHA staff has received questions about signs indicating that “abusive behavior will not be tolerated,” or that a facility has a “zero tolerance” policy for abuse. Some signs threaten prosecution, reminding patients and visitors that assault against a health care worker is a felony.

MHA cautions against using language that could be viewed by CMS to deter individuals from seeking emergency treatment or discourages them from remaining for an emergency medical screening exam. Phrasing an anti-violence message in terms of “zero tolerance” may be interpreted by CMS to violate EMTALA. A patient that is incapable or unwilling to conform his or her behavior as requested must still be provided an appropriate medical screening exam.

MHA believes that informing patients and visitors of expected and appropriate conduct in a health care facility can be beneficial in changing attitudes and behaviors toward health care workers. However, those messages must be conveyed in a manner that is less likely to result in EMTALA scrutiny. Members are encouraged to use language that describes the facility’s “expectations” for behavior or that educates patients and visitors on the toll such behaviors take on staff. MHA developed co-branded materials for use throughout the facility with the common theme of “Healing Happens Here.”

Examples of appropriate messages:

• Our staff is here to provide the best medical care to you and your loved ones with kindness and respect. We know it can be stressful visiting the hospital. Let us know how we can help.
• To receive the best care, be courteous and polite to your care team. Refrain from abusive language or physical threats.
• Tobacco use is not allowed on the hospital campus to support good health.
• For everyone’s safety, weapons are not allowed on the hospital campus.
• We partner with our local law enforcement professionals to provide a safe environment of care.
• Alcohol or illegal drugs are not allowed on the hospital campus, and visiting patients while under their influence is discouraged.

¹ ACEP Now. (2014, January 8). ED Waiting Room Posters on Prescribing Pain Medications May Violate EMTALA. Retrieved from https://www.acepnow.com/article/ed-waiting-room-posters-prescribing-pain-medications-may-violate-emtala/