Policy & Documentation
The Annotated WVP Plan: Section-by-Section Table of Contents
An annotated table of contents for a facility-specific written WVP plan — every required section, the primary source behind it, and what a surveyor opens it to find.
A facility-specific workplace violence prevention plan is graded on whether every required section is present, written to your facility, and backed by a record. The fastest way to build a defensible plan — and the fastest way to audit one you already have — is to start from a table of contents where each section is tied to the requirement it answers and to the evidence a surveyor opens it to find. This is that annotated outline.
#Why the table of contents is a compliance tool
A surveyor does not read a plan front to back. They look for the section that answers the question they are asking and check whether it is real. A plan organized around the requirements both Texas and The Joint Commission trace lets the surveyor find each element in seconds and signals a program that was built deliberately. A plan with strong prose but no recognizable structure forces the surveyor to hunt — and a surveyor who has to hunt presses harder. For the full drafting method behind each section, see our guide on how to write a facility-specific WVP plan.
The structure also defends against the most common citation: a generic template. When every section forces you to name your units, your committee, your reporting channel, the plan cannot stay generic.
#The annotated section list
Each row below is a plan section, the primary source that requires it, and what a surveyor opens that section to verify.
| Section | Source anchor | What the surveyor checks |
|---|---|---|
| 1. Commitment & scope | Plan adoption (Ch. 331); Leadership (TJC LD) | Leadership owns the program; the plan covers this facility |
| 2. Definitions & prohibited conduct | Facility-specific plan (Ch. 331); EC risk framing | Clear, usable definitions of violence and threats |
| 3. Committee & governance | Required committee (Ch. 331); program leader (TJC LD) | Required member categories; named program leader role |
| 4. Worksite analysis | Facility-specific basis (Ch. 331); annual analysis (TJC EC) | A dated, facility-specific assessment exists |
| 5. Prevention controls | Plan prevention measures; hazard control (OSHA) | Controls tied to identified hazards |
| 6. Reporting & anti-retaliation | Confidential reporting + anti-retaliation (Ch. 331) | The required protections, in the required language |
| 7. Training | At least annually (Ch. 331); orientation/annual/on-change (TJC HR) | The cadence and audience are stated |
| 8. Post-incident response | Acute treatment + assignment adjustment (Ch. 331) | A defined response, not an improvisation |
| 9. Annual plan evaluation | Annual evaluation to governing body (Ch. 331) | The recurring obligation is built in |
| 10. Document control | Provability discipline | Version, dates, and approval are shown |
#Section-by-section: what each must actually say
1. Commitment and scope. Open with a leadership commitment statement and a precise scope — which facility, which units, which workforce (including contracted and per-diem staff). This is the section that establishes the program is owned, not improvised, and it answers the Joint Commission's Leadership framing directly.
2. Definitions and prohibited conduct. Define workplace violence in terms staff can apply on the floor — physical assault, verbal threat, intimidation — and distinguish it from patient behavioral emergencies where care drives the behavior. Vague definitions produce underreporting, which surfaces in tracer interviews.
3. Committee and governance. Name the program leader by role and credential, never by name, and state the committee's composition. Under HSC Chapter 331, the committee must include an RN providing direct patient care, a physician providing direct care if any are employed, and a security-services employee if any are employed. State the meeting cadence and the governance line up to the governing body.
4. Worksite analysis. Reference your dated, facility-specific worksite analysis and the cadence on which it is repeated. This is the section that proves the rest of the plan is evidence-driven rather than theoretical.
5. Prevention controls. Describe the engineering, administrative, and work-practice controls that respond to the hazards your analysis found. Keep the framing compliance-oriented — controls and gaps, never guard or patrol deployment.
6. Reporting and anti-retaliation. State how staff report confidentially, name the channel, and include explicit anti-retaliation language that does not discourage contacting law enforcement. This section is read closely because Chapter 331 is most explicit here.
7. Training. State the cadence — at least annually under Chapter 331, and at orientation, annually, and on change under The Joint Commission — and the audience, including contracted staff.
8. Post-incident response. Define the response that runs after every event: acute treatment offered to affected staff and work-assignment adjustment considered. This is a distinct statutory obligation, not a sub-point of reporting.
9. Annual plan evaluation. State that the committee evaluates the plan annually and reports the results to the governing body — the recurring obligation that turns the plan into a living program.
10. Document control. Close with the version, effective date, last-reviewed date, and approving authority, under the same version-control discipline you apply across the program.
#Cross-reference instead of cramming
A strong plan is not a single document that contains everything. Sections should point — by name — to the operating procedures, the committee charter, the training plan, and the post-incident protocol that carry the detail. That keeps the plan readable and lets a surveyor follow the thread from the plan to the record without the plan becoming a 60-page binder no one maintains.
#Use the outline as an audit, too
The same table of contents is a self-audit. Walk your existing plan section by section against the list. If a section is missing, generic, or unbacked by a record, you have found a deficiency before a surveyor does. The sections most often missing entirely are the annual plan evaluation and a real post-incident response — both statutory, both easy to overlook in a template.
#How VIGILO helps
VIGILO authors the facility-specific written plan section by section, mapped to Chapter 331 and The Joint Commission and formatted for governing-body adoption, through the WVP Foundation Package and our policy and documentation development service. A Survey-Readiness Audit walks your current plan against this outline and flags every missing or generic section, and the Annual Compliance Subscription keeps each section current year over year.
VIGILO provides compliance, training, and consulting assistance and supports survey-readiness; it does not guarantee safety outcomes. Sources: Texas HSC Chapter 331 (SB 240, 88th Leg., 2023); 26 TAC §133.55; HHSC PL 2024-10; The Joint Commission workplace violence prevention requirements (effective Jan. 1, 2022 for hospitals); OSHA General Duty Clause §5(a)(1) and Publication 3148.