Your program passes on paper. Test it at 3am.
Sixty checks. Seven domains. Scored against what your staff can actually recall on nights. Includes a night shift verification worksheet.
Command: The binder is not the program
Most programs are assessed by reading the policy. This one is scored by asking the people working nights whether they can name the reporting path without looking it up. A control your staff cannot describe is a control you do not have. The included worksheet takes ten questions to one overnight shift in your highest risk unit.
Seven Domains
60 checks · scored 0 to 2 · max 120
Program Ownership
Who owns it and whether that ownership carries budget and reach. Named accountability, clinical representation, and whether contract and travel staff are covered by the same program.
Risk Assessment
Whether the worksite analysis reflects the building as staffed rather than as designed. Who participated, what triggered it, and whether findings were assigned to people with dates.
Recognition & Escalation
Whether staff can name a concern before it becomes an emergency. Training that is practiced rather than clicked through, and a path for concerns that are not yet urgent.
Physical Controls
Walk this with a nurse, not with facilities. Egress from exam rooms, duress alarms where staff are alone, and whether those alarms have been tested this quarter.
Reporting
The domain that fails most often and hides all the others. Whether reporting takes under three minutes, covers verbal abuse, needs no approval, and produces a reply.
Response & Duress
Team composition per shift, measured response times, drills that are not day shift only, and communication that reaches staff who cannot check a phone.
Post Incident
Whether anything changes afterward and whether staff believe it will. Proactive support on the shift it happened, blameless debriefs, and findings tracked to completion.
What your number means
Total your score against 120. The band tells you whether the gap is documentation, discipline, or shift coverage.
Program on paper
The documentation may satisfy a reviewer while staff have no working knowledge of it. Start with domain 05, because you cannot fix what is never reported.
Real but uneven
Usually strong on day shift and thin at night, or strong in the emergency department and absent elsewhere. Look for the gap between units rather than the average.
Working, with structural gaps
Most often domain 03 or 07: recognition happens informally, and post incident review does not change anything.
Mature program
What remains is the part self-assessment cannot reach, which is how staff actually behave under pressure when nobody is observing.
This is a readiness self-assessment, not a compliance audit and not legal advice. Accreditation and state requirements vary. Confirm your own obligations with counsel and your accrediting body.
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Workplace Violence Prevention Readiness Checklist downloads immediately. No waiting on email.