Table 5.

Summary of the 12 Steps in our systematic framework for addressing WPV in healthcare institutions, including the associated subprojects implemented at our healthcare institution for each step

Framework step number	Framework step	Step description	Evidence	Corresponding subproject
1	Define the Problem and Find the Data	WPV quality improvement projects should begin by clearly defining the problem and reviewing available data. Tools like the SEIPS 101 PETT scan help identify key elements and interactions within the work system, including barriers, risk factors, and facilitators, providing a comprehensive understanding of the WPV problem. This method is particularly useful for organizations that lack sufficient data due to issues like underreporting.	• Holden & Carayon, 2021 • Chung et al., 2014 • Cumbler et al., 2013 • Bokhoven et al., 2003 • Mento et al., 2020	SP1. Ongoing Literature Review of WPV-related topics SP3. Implementing quality indicators to an organization-wide WPV dashboard SP4. Changing the perception of safety and support in HCPs during Code White and WPV incidences
2	Assemble a WPV QI team	Addressing WPV is a complex task that will require a well-rounded interdisciplinary team. The team should include individuals with diverse perspectives, skill sets, and backgrounds and should emphasize collaboration and creativity in order to have effective WPV quality improvement.	• Chung et al., 2014 • Kaplan et al., 2012 • Hulscher et al., 2013	This relates to the approach taken for the systems level QI project.
3	Listen to Frontline Staff	Collecting qualitative data from frontline staff is crucial for WPV initiatives. WPV contributes to HCP burnout, high turnover rates, and reduced quality of care; ensuring HCPs feel heard fosters a sense of organizational support and yields valuable insights. Integrating both qualitative and quantitative data through interviews and surveys enables organizations to better understand WPV, support staff, and guide QI efforts. A mixed-methods approach, including longitudinal data, enhances intervention effectiveness and secures key collaborators' buy-in.	• Schulz-Quach et al., 2022 • Shanafelt et al., 2020 • Crowe et al., 2017 • Calman et al., 2013 • Sachdeva et al., 2007 • Franco et al., 2011	SP4. Changing the perception of safety and support in HCPs during Code White and WPV incidences
4	Key Collaborator Engagement	Active engagement with key collaborators, especially organizational leadership, is essential for the success of WPV QI projects. Leadership buy-in ensures resource availability, fosters cultural change, and supports the sustainability of ongoing WPV initiatives like training. Early involvement, clear communication, and including key collaborators in decision-making are critical to maintaining their long-term support.	• Kaplan et al., 2012 • Fryer et al., 2007 • Kaplan et al., 2010 • Brandrud et al., 2011 • Guise et al., 2013	This relates to the approach taken for the systems level QI project.
5	Bringing Organizational Entities Together	Addressing WPV requires collaboration beyond the QI team, involving representatives from all functional units to ensure a comprehensive understanding of the problem. However, siloed operations in healthcare institutions often hinder efficiency and can undermine organization-wide initiatives like WPV prevention. Effective communication between departments must be established early, as demonstrated in our case, where eight distinct functional units addressing WPV were identified and brought together before initiating change.	• Chung et al., 2014 • Alves et al., 2018 • Akmal et al., 2021	This relates to the approach taken for the systems level QI project.
6	Implement an Effective Governance Structure	An effective WPV governance structure is vital to project success, providing leadership, preventing conflicts, managing resources, and ensuring sustainability. In our large organization, multiple governance structures were developed alongside existing departments to support the WPV QI initiative. The governance framework should include leadership from all relevant functional units, with a clear charter outlining roles, budgeting, goal alignment, and data sharing. Additionally, presenting to senior executives is essential for securing full organizational endorsement.	• Kaplan et al., 2012 • Fryer et al., 2007 • Derakhshan et al., 2019 • Jones et al., 2017	SP6. Implementation of a dedicated UHN Code White Governance Committee
7	Assess Project viability and Monitor Progress and Engagement of Functional Units	Assessing viability and monitoring project execution are crucial for multi-level WPV initiatives to achieve successful outcomes. The DICE framework, developed by the Boston Consulting Group, evaluates key factors such as project duration, team integrity, commitment of senior executives and frontline collaborators, and the additional effort required from staff. Continuous monitoring helps maintain engagement and commitment, particularly in the face of delays and resource constraints, ensuring the sustained progress of WPV initiatives.	• Hughes, 2021 • Sirkin et al., 2005 • Day et al., 2017 • Raza et al., 2023 • Ziółkowski et al., 2006	This relates to the approach taken for the systems level QI project.
8	Connect with the Community	In addressing WPV, it was crucial to include patients, chosen family members, and visitors, as they experience various stressors during healthcare visits that can trigger stress responses, minority stress, and responsive behaviour, potentially leading to WPV incidents. A trauma-informed and inclusive approach is necessary to create a safe environment for these groups. Engaging with these groups through surveys, advisory boards, and involvement in developing initiatives offers valuable perspectives on WPV. It is essential to foster meaningful and authentic engagement to avoid feelings of under appreciation or tokenism among patients.	• Muskett, 2014 • Beattie et al., 2019 • Schulz-Quach et al., 2023 • Ashworth et al., 2023 • Armstrong et al., 2013 • Baker et al., 2016 • McNeill et al., 2020	SP12. Patient partners and community outreach
9	Implement a Cohesive and Clear Communication Strategy	Effective organizational communication is crucial for the success of WPV QI initiatives. Clear and cohesive communication from leadership helps staff understand the organization's direction, which enhances HCP buy-in and engagement. Inconsistent communication can lead to rumours and create divisions that undermine cohesiveness and trust. Successful WPV initiatives can be shared through various channels, including newsletters, emails, websites, meetings, and leadership updates. Utilizing existing communication strategies increases effectiveness, and establishing a communication channel between site managers and the WPV QI team allows for valuable site-specific feedback.	• Boan & Funderburk, 2003 • Brown, 2020 • Seijts & Crim, 2006 • Simmonds, 2006 • Agency for Healthcare Research and Quality, 2017 • Kellogg et al., 2017	SP9. Implementing Environmental Indicators for harm reduction and risk minimization
10	Implement Data Monitoring and Utilize Statistics for Planning/Management Decisions	Measuring changes in regions of interest related to WPV over time is essential for assessing the impact of WPV QI initiatives. However, current WPV metrics in healthcare often focus solely on outcome indicators, such as the frequency of documented incidents, which are problematic due to the historical underreporting of WPV. To effectively monitor WPV, healthcare institutions need a broader set of quality indicators that encompass structure, process, and outcome measures, providing a comprehensive view of WPV within the organization.	• Keith & Brophy, 2021 • Lyver et al., 2024 • Sethi et al., 2024 • Byon et al., 2022 • Itri et al., 2017	SP2. Identifying quality indicators for measuring change in quality of care related to Code White and WPV incidences SP3. Implementing quality indicators to an organization-wide WPV dashboard
11	Improve Debriefing and Reporting	Improving debriefing and reporting protocols in healthcare institutions enhances HCP well-being and organizational culture, which are vital for increasing buy-in and incident reporting. Effective debriefing minimizes adverse outcomes by providing support and validation without placing blame. Addressing the underreporting of WPV, a consistent issue in healthcare, requires a robust, accessible reporting system that minimizes staff workload and includes follow-up communication. Education and debriefing interventions should promote these reporting systems to foster a culture of reporting, ensuring staff feel supported and cared for.	• Shanafelt et al., 2020 • Antai-Otong, 2001 • Fricke et al., 2023 • Juarez, 2021 • Rodrigues et al., 2021 • Arnetz, 2022 • Johnson, n.d. • Thomas et al., 2021	SP7. Reviewing, updating and implementing incident reporting for WPV and Code White incidents SP10. Code White hot and cold debriefing process and debriefing escalation algorithm
12	Implement Comprehensive Training Plan based on HCP’s Environmental Risks	Implementing a new or updated training plan tailored to staff needs is essential for addressing WPV in healthcare. Effective training enhances WPV management, increases staff safety, and fosters a culture of safety within the organization. Training should encompass simulation and education programs focused on WPV awareness, de-escalation, agitation management, decision-making, crisis intervention, and conflict resolution. Since factors such as department, patient interaction frequency, and WPV concerns influence the likelihood of involvement in incidents, training should be based on risk profiles rather than solely on profession. This approach fosters interdisciplinary understanding, enhances interprofessional communication, and improves teamwork.	• Keith & Brophy, 2021 • Beech & Leather, 2006 • Martinez, 2017 • Alafean & Dalahmeh, 2022 • Liu et al., 2020 • Walton et al., 2019	SP5. Implementation of educational intervention I SP8. Implementation of educational intervention II