EBECRA15Sample Risk Assessment Hospital

Includes Flash Drive!
Environment of Care
®
Risk Assessment
SECOND EDITION
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CONTENTS
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Chapter 1: Risk-Assessment Basics . . . . . . . . . . . . . . . . . . . . . . . . . 7

Consequences of Not Performing Risk Assessments . . . . . . . . . . . . . . . . . . 17
Identifying Issues That Require a Risk Assessment . . . . . . . . . . . . . . . . . . . 17
What The Joint Commission Requires . . . . . . . . . . . . . . . . . . . . . . . . . 18
Types of EC Risk Assessments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Methods Used to Conduct Risk Assessments . . . . . . . . . . . . . . . . . . . . . . 24
The Risk-Assessment Cycle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
Case Study: Storage of Endoscope Supplies . . . . . . . . . . . . . . . . . . . . . 31
Chapter 2: Safety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
Overview of Safety Risk Assessments . . . . . . . . . . . . . . . . . . . . . . . . . 37
Environmental Tours . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
Worker Safety Risk Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
The Job Hazard Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
Special Risk Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
Case Study: Assessing Risk in Satellite Behavioral Health Care Facilities . . . . . . 63
Chapter 3: Hazardous Materials and Waste . . . . . . . . . . . . . . . . . . . . . 67

Overview of Assessing Risks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
Inventory Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
Special Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85
Chapter 4: Security . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89
Overview of Assessing Risks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89
Identifying Risks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90
Risks Associated with the Workplace . . . . . . . . . . . . . . . . . . . . . . . . . . 91
Specific Patient Populations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97
Technology and Data Security . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99
Case Study: Assessing Risk of Shootings . . . . . . . . . . . . . . . . . . . . . . 101
Environment of Care® Risk Assessment | Second Edition
Chapter 5: Fire and Life Safety . . . . . . . . . . . . . . . . . . . . . . . . . . . 103

Fire Safety and Life Safety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103
Overview of Assessing Risks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103
The Statement of Conditions™ . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105
Interim Life Safety Measures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120
Equivalencies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121
The Human Factor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125
Case Study: Assessing Risk of Corridor Clutter . . . . . . . . . . . . . . . . . . . 128
Chapter 6: Medical Equipment . . . . . . . . . . . . . . . . . . . . . . . . . . . 131

Equipment Selection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132
The Medical Equipment Management Program . . . . . . . . . . . . . . . . . . . . 134
Maintenance Strategies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134
Special Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 136
Chapter 7: Utilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143

Creating a Risk-Based Inventory . . . . . . . . . . . . . . . . . . . . . . . . . . . 145
Maintenance Strategies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146
Possible Utility Failures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146
Special Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 148
Chapter 8: Emergency Management . . . . . . . . . . . . . . . . . . . . . . . . 153

Hazard Vulnerability Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 154
Emergency Operations Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161
Emergency Response Exercises . . . . . . . . . . . . . . . . . . . . . . . . . . . 162
To Sum Up . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163
Chapter 9: Construction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165

The Infection Control Risk Assessment . . . . . . . . . . . . . . . . . . . . . . . . 171
Implementing the PCRA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 182
Interim Life Safety Measures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 182
Other PCRA Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 182
Documenting the Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183
Chapter 10: Intracycle Monitoring . . . . . . . . . . . . . . . . . . . . . . . . . 185

ICM Basics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185
Focused Standards Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . 186
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 191
4
Introduction
Risk is an issue we, as individuals, encounter daily—be it An effective EC risk-management program helps to
in our personal or professional lives. In response, we assess proactively identify these types of risks and put plans,
these risks to determine potential outcomes, then, following processes, procedures, and programs in place to address,
our assessment, decide on a course of action. In the simplest eliminate, or counteract the effects of these risks.
terms, a risk assessment is a systematic method that
accomplishes the following: Environment of Care Risk Assessment®, Second Edition,
introduces and discusses the various risk-assessment
• Determines the potential negative consequences (risks) processes within the environment of care. This book
of an action or situation is designed to help health care organizations develop
• Evaluates the extent of those risks and implement a comprehensive EC risk-assessment
• Decides whether to accept, mediate, or avoid those risks and reduction program. To this end, the book provides
suggestions on how to design and implement a proactive
Risk assessments can vary widely in form and application, risk-assessment process and conduct effective risk
from a quick examination and judgment of a situation, to assessments that address the various components of
a formalized set of procedures and policies that are carefully the environment of care, as well as tools to support the
documented. risk‑assessment process.
As in our personal day-to-day life, health care settings To be most effective, risk assessment should be approached
are fraught with risk. They are full of possible challenges, as a multidisciplinary process. This book is intended
hazards, and negative situations. Nowhere is this more for anyone who can and should participate in an EC
apparent than in the environment of care (EC). EC risks risk‑assessment activity, including, but not limited to,
include, but are not limited to, the following: the following:
• Patient falls • Safety officers

• Needlestick injuries • Risk managers
• Hazardous materials exposure • EC management—such as facilities managers, security
• Security threats managers, and emergency management leaders
• Fires • Clinical engineers
• Medical equipment malfunctions • Nurses
• Utility outages • Pharmacists
• Emergency situations • Infection control personnel
• Spread of infection during construction, renovation, • Organization leaders
and demolition activities
5
By taking a proactive approach to assessing risks in the Acknowledgements

environment of care, organizations can achieve a safer This second edition of Environment of Care Risk Assessment®
environment for staff, visitors, and patients, while would not have been possible without our writer, Lea Anne
improving the quality of care they provide. Stoughton, and our subject matter expert, Katherine
Tolomeo, CHEM, CHSP. Their commitment to ensuring
What’s New in This Edition that this book provides you with the most up-to-date and
This edition includes expanded or new chapters on fire accurate information, in a user-friendly format, has been
safety, hazardous materials and waste, construction, and invaluable. In addition, we are grateful for the real-world
Intracycle Monitoring (ICM). Information has been scenarios provided by the Gateway Foundation,
updated throughout to reflect current standards and Northwestern Memorial Hospital, Tampa General Hospital,
requirements, including details on the following: and UW Health. Their contributions provide a unique
perspective you can review and apply to your organization.
• Safety risks outside the building Finally, we are deeply indebted to our Joint Commission
• Safety data sheets and labeling requirements reviewers (see copyright page for the names of these
• Alternative equipment maintenance (AEM) for medical individuals).
equipment and utilities
• Data security
• E-cigarettes
• Emergency exercises
• Construction strategies that support risk management
Contents of This Book

Chapter 1 provides a general overview of risk management,
its importance to an organization, and suggestions for
implementing a proactive risk-assessment process.
Chapters 2 through 8 offer information on risk assessments

specific to different aspects of the environment of care, in
the following order:
• Safety
• Hazardous materials and waste
• Security
• Fire and life safety
• Medical equipment
• Utilities
• Emergency management
Chapter 9 discusses specific risks that arise during a demoli-

tion, construction, or renovation project.
Chapter 10 closes out the book with information about the

role of ICM in managing risk.
6
CHAPTER
1
Risk-Assessment Basics
People encounter risk every day. Should I drive my car CONSIDER THIS… ■
to work during a snowstorm? Should I eat a fast-food
hamburger at lunch? We assess those risks to make the best In deciding what to eat for lunch, you may take the
decisions we can. following points into account to help identify the risks
choosing a fast-food option:
CONSIDER THIS… ■
Eating out could lead to heartburn and weight
gain, as well as impact your wallet, but it is a
When deciding whether to drive to work through a
quick option
snowstorm or forego the drive and stay home, your
► RESULT 1: Due to three back-to-back meetings,
risk assessment could identify the following:
going to the fast-food restaurant across the street
will be the most time-effective option.
There is a high potential for bad traffic during the
snowstorm. ► RESULT 2: You opt to order a salad to ensure
► RESULT: You opt for public transportation, that you aren’t suffering from heartburn the rest
determining that the risk of getting stuck in traffic of the day.
is too great.
Eating healthy and making smart financial
The traffic risk is manageable, but the potential choices are more important than the ease of
safety risks are not. picking up a hamburger.
► RESULT: You make arrangements to work from ► RESULT : You prepare your lunch each night to
home that day and avoid traveling in the snow ensure that you are eating healthy and saving
altogether. money.
Although a risk-assessment process in health care can be Why Assess Risks?

as informal as the storm and lunch examples, the most There are many reasons to perform risk assessments in
successful risk assessments use an established process to health care. Risk assessments can improve safety, security,
help identify and assess the level of risk associated with and efficiency—even in complex or unique situations;
a particular action, decision, process, project, or hazard. identify needs and opportunities for training, education,
This process also helps shape activities that lessen or elim- and performance improvement; justify needs, such as
inate the identified risks or the consequences that result staffing, space, or equipment; evaluate changes; and inform
from those risks. This process helps guide the assessment “big-picture” activities such as strategic planning.
and ensures that all components of the assessment are
conducted adequately.
7
The following sections explore these reasons in greater detail. exist. A risk assessment can help probe for information
about a question or situation and identify potential
Improve Patient and Staff Safety and Security solutions. Organizations then can use the information
Safety is one of the most important aspects of providing gathered to make an educated guess and begin down the
health care. Therefore, it is important to conduct risk road toward a solution.
assessments to identify, mitigate, and resolve threats to
patient and staff safety—to help improve safety across the CONSIDER THIS… ■
entire organization.
A nurse calls a safety manager to ask if the intensive
Every risk assessment affects patient and staff safety in some care unit (ICU) can store needles or sharps at the
bedside. This sounds like a bad idea because of all
way. How a risk assessment improves patient and staff safety
the traffic in the ICU; however, there are no Joint
depends on the type of risk assessment and whether it can
Commission standards or other regulations stating
directly or indirectly protect patients and staff. Examples of that nurses cannot store sharps at the bedside. In
safety risk assessments include the following: addition, there is no best-practice information on the
concept, and the organization has not dealt with this
• Organizationwide employee safety risk assessment. Used to issue before. So the safety manager conducts a risk
identify and protect staff members from risks associated assessment to ascertain the potential risks associ-
with their work environments ated with storing sharps at the bedside, as well as
the potential benefits to staff.
• Process-based, safety risk assessment. Used to review a
process—such as storing sharps at the bedside—to look
After weighing the pros and cons, the safety manager
for potential ways to eliminate a possible patient or
decides to allow the storage of sharps at the bedside
workplace injury but determines the issue will need to be closely
• Security risk assessment. Used to identify areas of potential monitored. If any incidents occur because a patient,
security risk—such as dark parking lots, thick shrubbery child, or visitor gains access to these unsecured
around building exits, or areas not covered by security sharps, this process will change immediately. All
cameras—that could lead to a security incident with a parties agree. The safety manager assigns a
patient or staff member if not addressed representative from the ICU to attend the monthly
safety committee meetings to report the status. The
• Medical equipment risk assessment. Used to evaluate and
organization documents the process through the
reveal pieces of equipment that are prone to failure and
minutes of the safety committee. Every month the
could result in patient harm if not addressed ICU nurse manager reports to the safety committee
to discuss how the process is going. By using a
Improve Efficiency proactive risk-assessment process, the organization
Just because organizations have processes in place does not is able to confidently address a need, knowing that
mean that those processes are efficient. In fact, many times all the positives and negatives associated with that
organizations engage in activities using a particular method question have been considered.
simply because the have “always” used it or because they
have adopted the method from another organization. By
conducting risk assessments, organizations can identify Identify Training and Education Opportunities
processes that are inefficient and ineffective and determine Risk assessments can be valuable training tools because they
potential ways to improve efficiency, accuracy, and identify hazards, build awareness about potentially negative
appropriateness. situations, and point toward resolutions to those situations.
For example, a security risk assessment can be used to
Develop Solutions for Complex or Unique Situations discuss potential security issues within organizations or
Typically, the actions of health care organizations are guided within security-sensitive areas. Using it as a teaching tool,
by regulations, best practices, lessons learned, and so forth. the assessment can build awareness about those issues and
However, there may be situations in which no such tools any programs in place to reduce security risks.
8
Chapter 1 | Risk-Assessment Basics
housed. He compiles the results in a dashboard. The

Organizations also can use formalized risk assessments to air quality test results are color coded in red, which
guide development of their education programs, by indicates they are outside of acceptable ranges. This
identifying areas where further education is needed to visual tool—essentially a risk assessment—helps the
achieve safe delivery of care. For example, a risk assessment facilities manager demonstrate the need for a new
that looks at potential suicide risks for psychiatric patients air-handling unit to the CEO. (See Figures 1-1
may identify the need for further staff training on suicide through1-3 on pages 10–16 for dashboarding
and the environmental risks associated with suicide. Such samples.)
an assessment could identify gaps in staff knowledge and
areas that need improvement.
Evaluate the Effect of Changes
Identify Performance Improvement Opportunities Every organization will periodically change its processes,
The Joint Commission requires organizations to conduct procedures, and policies to reflect new standards, or in
performance improvement activities. Risk assessments can response to a performance improvement project or other
pinpoint specific areas to be improved—for example, driver. Performing risk assessments potentially can deter-
hand-hygiene compliance or staff reaction time during a fire mine whether the change is managing the risk it is designed
emergency. Leadership can and should use risk assessments to manage, as well as expose any new risks that may emerge
to prioritize performance improvement initiatives for the as a result of the change.
organization. Issues that are high risk, problem prone, and
high volume should be given priority. An identified risk CONSIDER THIS… ■
that has a wide scope and significant potential for harm may
be targeted for improvement before a risk that has limited A new hand-hygiene policy in a health care facility
scope or less impactful consequences. Or a risk that directly results in the installation of touch-free faucets in
patient-care rooms. After the faucets are in use, the
affects patient safety on a daily basis may be given priority
infection preventionist performs a risk assessment
over an environmental risk that may or may not occur.
discovering that the new faucets are harboring
Legionella. It is determined that environmental
Justify a Need services has been cleaning the new faucets the
Often the need for new equipment, staff, or space will go same way as the old faucets, because they were not
unmet because of budget or time constraints. The affected given the different instructions from the manufacturer
department or unit may need to justify its need, explaining of the new faucets.
to leadership what is needed and the consequences of
not providing it. Risk assessments can serve this purpose
by focusing attention on a need and the consequences of Inform Long-Term Goals
meeting the need, and providing a clear solution. Long-term—or “big-picture”—goals and strategic plans are
based on data. One source of those data is risk assessments.
CONSIDER THIS… ■ The information gleaned from risk assessments can help
leadership make decisions about expanding or eliminating
The facilities manager in a large community hospital services, construction or renovation projects, and which
notices during a visual inspection that the floor deck investments support the hospital’s overall mission and serve
of the air-handling unit is rusting out. He identifies
to meet its patient safety goals.
the need to replace the current air-handling unit in
his annual evaluation presented to senior leadership.
However, after numerous requests, he receives no
support because of lack of funding.
When a new CEO arrives, the facilities manager

once again makes the case for a new air-handling
unit. This time, he tests the air quality in the ICUs and
two oncology units, where vulnerable patients are
9
FIGURE 1-1
DASHBOARDING SAMPLE—STANDARD ANALYSIS WORKSHEET

EC.02.05.01 The hospital manages risks associated with its utility systems. 1st Quarter 2nd Quarter 3rd Quarter 4th Quarter
In-Depth
Data Non- Non- Non- Non- Overall
EP Category Deficiency red Description Compliant compliant Compliant compliant Compliant compliant Compliant compliant Compliance
The hospital designs and installs utility

1 A SLD systems that meet patient care and 87.50% 12.50% 87.50% 12.50% 93.00% 7.00% 96.50% 3.50% 91.13%
operational needs.
Written inventory of operating

2 C SLD 100.00% 0.00% 79.50% 20.50% 84.50% 15.50% 100.00% 0.00% 91.00%
components of utility systems
Written documentation that high-risk

3 C SLD components on the inventory have been 100.00% 0.00% 100.00% 0.00% 84.50% 15.50% 100.00% 0.00% 96.13%
identified
Written documentation of activities and

4 C SLD frequencies for inspecting, testing, and 100.00% 0.00% 100.00% 0.00% 84.50% 15.50% 98.30% 1.70% 95.70%
maintaining operating components
Written documentation of activities and

frequencies for inspecting, testing, and
5 A SLD 100.00% 0.00% 100.00% 0.00% 84.50% 15.50% 98.30% 1.70% 95.70%
maintaining equipment in accordance
with manufacturers’ recommendations
Qualified individual utilizes written

6 A SLD 100.00% 0.00% 100.00% 0.00% 84.50% 15.50% 98.30% 1.70% 95.70%
criteria to support alternative methods
Written documentation of operating

7 C SLD components with alternative equipment 100.00% 0.00% 100.00% 0.00% 84.50% 15.50% 98.30% 1.70% 95.70%
maintenance program
Utility system controls are labeled

8 A SLD for partial or complete emergency 93.54% 6.46% 83.50% 16.50% 90.00% 10.00% 95.00% 5.00% 90.51%
shutdowns.
Written procedures for responding to

9 A SLD N 88.88% 11.12% 100.00% 0.00% 100.00% 0.00% 90.00% 10.00% 94.72%
utility system disruptions
Electricity Yes Yes Yes Yes
Natural Gas Yes Yes Yes Yes
Medical Air Yes Yes Yes Yes
Vacuum Yes Yes Yes Yes
HVAC (Heating, Ventilating, and Air

Yes Yes Yes Yes
Conditioning)
Water Yes Yes Yes Yes
Sanitation No No No Yes
Communication Systems Yes Yes Yes Yes
Information Technology Yes Yes Yes Yes
Elevator No
Procedures address shutting off the

10 A SLD malfunctioning system and notifying staff 100.00% 0.00% 100.00% 0.00% 94.50% 5.50% 94.50% 5.50% 97.25%
in affected areas.
Procedures address performing

11 A SLD emergency clinical interventions during 95.00% 5.00% 100.00% 0.00% 100.00% 0.00% 100.00% 0.00% 98.75%
utility system disruptions.
Procedures address how to obtain

12 A SLD 100.00% 0.00% 100.00% 0.00% 94.50% 5.50% 94.50% 5.50% 97.25%
emergency repair services.
Hospital responds to utility system

13 A SLD disruptions as described in its 92.30% 7.70% 83.33% 16.67% 93.50% 6.50% 95.45% 4.55% 91.15%
procedures.
Minimizes pathogenic biological

agents in cooling towers, domestic
14 A CLD 95.60% 4.40% 86.67% 13.33% 87.00% 13.00% 95.00% 5.00% 91.07%
hot- and cold-water systems, and other
aeroloizing water systems.
Appropriate pressure relationships,

air-exchange rates, and filtration
15 A CLD Y 76.54% 23.46% 74.56% 25.44% 64.26% 35.74% 77.20% 22.80% 73.14%
efficiencies in areas designed to
control airborne contaminants
Air-Pressure Relationship 59.57% 40.43% 46.81% 53.19% 34.04% 65.96% 57.45% 42.55% 49.47%
KPI Analysis Air-Exchange Rates 79.30% 20.70% 88.60% 11.40% 80.25% 19.75% 85.90% 14.10% 83.51%
Filtration Efficiencies 90.74% 9.26% 88.26% 11.74% 78.50% 21.50% 88.26% 11.74% 86.44%
16 A SLD Utility systems have maps of distribution. 100.00% 0.00% 100.00% 0.00% 93.00% 7.00% 100.00% 0.00% 98.25%
109.94% 8.81% 107.42% 11.33% 100.60% 18.15% 110.18% 8.57%
10
FIGURE 1-1
DASHBOARDING SAMPLE—STANDARD ANALYSIS WORKSHEET continued
Non-
Compliance compliance
EP Percentage Percentage
1 91.13% 8.88%
2 91.00% 9.00%
3 96.13% 3.88%
4 95.70% 4.30%
5 95.70% 4.30%
6 95.70% 4.30%
7 95.70% 4.30%
8 90.51% 9.49%
9 94.72% 5.28%
10 97.25% 2.75%
11 98.75% 1.25%
12 97.25% 2.75%
13 91.15% 8.86%
14 91.07% 8.93%
15 73.14% 26.86%
16 98.25% 1.75%
EC.02.05.01 Element of Performance Compliance Rate
100.00%
Compliance
Percentage 0.00%
90.00% Noncompliance
Percentage
80.00%
10.00%
70.00%
20.00%
60.00%
50.00%
30.00%
40.00%
40.00%
30.00%
20.00%
40.00%
10.00%
50.00%
0.00%
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
EP, element of performance; SLD, Standard Level Deficiency; CLD, Condition Level Deficiency; KPI, key performance indicator. 60.00%
11
70.00%
FIGURE 1-2
DASHBOARDING SAMPLE—IN-DEPTH DATA ANALYSIS WORKSHEET
EC.02.05.01 EP 15, Air-Pressure Relationships—Daily Verification of Appropriate Air Pressure for In-Use Rooms
1st Quarter 2nd Quarter 3rd Quarter 4th Quarter Total
Non- Non- Non- Non- Non- Overall

Measurement Compliant compliant Compliant compliant Compliant compliant Compliant compliant Compliant compliant Compliance
OR 1 (2) 174 6 157 23 148 34 157 25 636 88 87.85%
OR 2 (2) 170 10 164 16 153 29 155 27 642 82 88.67%
AHU 1
OR 3 (2) 149 16 176 12 92 17 92 0 509 45 91.88%

OR 4 (2) 147 11 123 12 120 14 156 0 546 37 93.65%
PACU (2) 152 7 147 9 143 13 129 27 571 56 91.07%
Clean Core 1 (4) 312 48 337 27 301 59 303 57 1253 191 86.77%
OR 5 (2) 152 0 154 0 156 0 156 2 618 2 99.68%
OR 6 (2) 152 0 154 0 156 0 156 2 618 2 99.68%
OR 7 (2) 152 0 154 2 156 1 156 0 618 3 99.52%
AHU 2
OR 8 (2) 152 0 154 1 156 2 156 0 618 3 99.52%

OR 9 (2) 152 3 154 2 156 0 156 1 618 6 99.04%
Circulation Corridor 1 (2) 152 0 154 4 156 1 156 0 618 5 99.20%
Circulation Corridor 2 (2) 152 0 154 0 156 3 156 0 618 3 99.52%
OR Sterile Storage (3) 270 2 273 0 276 0 273 3 1092 5 99.54%
Clean Core 2 (4) 360 0 360 4 368 0 368 0 1456 4 99.73%
Clean Core 3 (4) 360 0 364 0 362 6 368 0 1454 6 99.59%
AHU 3
Clean Core 4 (4) 227 1 228 3 232 2 234 0 921 6 99.35%

IR 1 (2) 180 0 176 0 179 1 175 0 710 1 99.86%
IR 2 (2) 151 1 152 2 155 1 155 1 613 5 99.19%
IR Sterile Storage (1) 90 0 91 0 92 0 92 0 365 0 100.00%
Endo 1 (2) 166 0 172 1 181 3 183 1 702 5 99.29%
Endo 2 (2) 152 1 148 6 156 0 153 3 609 10 98.38%
Endo 3 (2) 152 0 154 0 154 2 156 0 616 2 99.68%
Endo 4 (2) 152 0 154 0 154 2 151 5 611 7 98.87%
AHU 4
Endo Sterile Storage (2) 180 0 182 0 184 1 184 0 730 1 99.86%
Endo Decontamination (2) 180 0 182 0 183 1 180 4 725 5 99.32%
Vascular 1 (2) 158 0 161 0 140 0 143 0 602 0 100.00%
Vascular 2 (2) 152 0 154 0 156 0 156 0 618 0 100.00%
Vascular Sterile Storage (1) 180 0 182 0 184 0 184 0 730 0 100.00%
L&D OR 1 (2) 178 2 179 3 182 2 182 2 721 9 98.77%
L&D OR 2 (2) 180 0 181 1 182 2 184 0 727 3 99.59%
L&D OR 3 (2) 149 0 161 0 175 0 173 0 658 0 100.00%
AHU 5
L&D Sterile Storage (1) 90 0 91 0 92 0 92 0 365 0 100.00%

ICU Isolation 1 (2) 178 6 173 5 184 3 184 1 719 15 97.96%
ICU Isolation 2 (2) 176 4 182 0 184 1 184 0 726 5 99.32%
NICU Isolation 1 (2) 179 1 176 3 184 2 184 0 723 6 99.18%
NICU Isolation 2 (2) 177 9 182 5 184 4 184 1 727 19 97.45%
Medical Isolation A (2) 152 0 154 0 156 1 156 0 618 1 99.84%
Medical Isolation B (2) 180 0 182 0 182 2 184 0 728 2 99.73%
AHU 6
Post-Op Isolation C (2) 176 0 182 1 180 0 178 0 716 1 99.86%

Post-Op Isolation D (2) 180 0 182 0 184 0 184 1 730 1 99.86%
Pharmacy 180 0 168 14 167 17 179 2 694 33 95.46%
Laboratory A 160 1 133 9 150 6 164 0 607 16 97.43%
Laboratory B 176 0 182 0 180 0 178 0 716 0 100.00%
AHU 7
Laboratory C 158 0 161 0 140 0 143 0 602 0 100.00%

Central Sterile—Clean (5) 450 3 455 5 460 1 460 2 1825 11 99.40%
Central Sterile—Dirty (6) 348 102 536 10 526 32 549 3 1959 147 93.02%
59.57% 40.43% 46.81% 53.19% 34.04% 65.96% 57.45% 42.55% 17.02% 82.98%
12
FIGURE 1-2
DASHBOARDING SAMPLE—IN-DEPTH DATA ANALYSIS WORKSHEET continued
Air-Pressure Relationships—Daily Verification of

Appropriate Air Pressure for In-Use Rooms
Non- Non-
Compliance compliance Compliance compliance
Measurement Percentage Percentage Measurement Percentage Percentage
OR 1 (2) 87.85% 12.15% OR 1 87.85% 12.15%
OR 2 (2) 88.67% 11.33% OR 2 88.67% 11.33%
OR 3 (2) 91.88% 8.12% OR 3 91.88% 8.12%
OR 4 (2) 93.65% 6.35% OR 4 93.65% 6.35%
PACU (2) 91.07% 8.93% PACU 91.07% 8.93%
Clean Core 1 (4) 86.77% 13.23% Clean Core 1 86.77% 13.23%
OR 5 (2) 99.68% 0.32% Pharmacy 95.46% 4.54%
OR 6 (2) 99.68% 0.32% Central Sterile—Dirty (6) 93.02% 6.98%
OR 7 (2) 99.52% 0.48%
OR 8 (2) 99.52% 0.48%
OR 9 (2) 99.04% 0.96%
Circulation Corridor 1 (2) 99.20% 0.80%
Circulation Corridor 2 (2) 99.52% 0.48%
OR Sterile Storage (3) 99.54% 0.46%
Clean Core 2 (4) 99.73% 0.27%
Clean Core 3 (4) 99.59% 0.41%
Clean Core 4 (4) 99.35% 0.65%
IR 1 (2) 99.86% 0.14%
IR 2 (2) 99.19% 0.81%
IR Sterile Storage (1) 100.00% 0.00%
Endo 1 (2) 99.29% 0.71%
Endo 2 (2) 98.38% 1.62%
Endo 3 (2) 99.68% 0.32%
Endo 4 (2) 98.87% 1.13%
Endo Sterile Storage (2) 99.86% 0.14%
Endo Decontamination (2) 99.32% 0.68%
Vascular 1 (2) 100.00% 0.00%
Vascular 2 (2) 100.00% 0.00%
Vascular Sterile Storage (1) 100.00% 0.00%
L&D OR 1 (2) 98.77% 1.23%
L&D OR 2 (2) 99.59% 0.41%
L&D OR 3 (2) 100.00% 0.00%
L&D Sterile Storage (1) 100.00% 0.00%
ICU Isolation 1 (2) 97.96% 2.04%
ICU Isolation 2 (2) 99.32% 0.68%
NICU Isolation 1 (2) 99.18% 0.82%
NICU Isolation 2 (2) 97.45% 2.55%
Medical Isolation A (2) 99.84% 0.16%
Medical Isolation B (2) 99.73% 0.27%
Post-Op Isolation C (2) 99.86% 0.14%
Post-Op Isolation D (2) 99.86% 0.14%
Pharmacy 95.46% 4.54%
Laboratory A 97.43% 2.57%
Laboratory B 100.00% 0.00%
Laboratory C 100.00% 0.00%
Central Sterile—Clean (5) 99.40% 0.60%
Central Sterile—Dirty (6) 93.02% 6.98%
13
FIGURE 1-2
DASHBOARDING SAMPLE—IN-DEPTH DATA ANALYSIS WORKSHEET continued

EC.02.05.01 EP 15 Areas of Noncompliance
100.00%
Compliance
Percentage
98.00% Noncompliance
Percentage
96.00%
94.00%
92.00%
90.00%
88.00%
86.00%
84.00%
82.00%
80.00%
OR 1 OR 2 OR 3 OR 4 PACU Clean Core 1 Pharmacy Central Sterile—
Dirty (6)
OR 1, OR 2, OR 3, OR 4, PACU and Clean Core 1: 1989 system that has a very extensive PM system due to the age of the
equipment; 129 OR cases in the past year have been rescheduled, moved, or postponed due to a malfunctioning system and
approximately $53k in repairs.
Pharmacy: Staff error due to not having the system on when required or propping door open. Manager follow-up and staff
education and accountability.
Central Sterile Supply: Multiple issues—department error by not monitoring one pressure relationship from the dirty side into
a staff work area, an electrical mechanical door holder that was removed from a door entering the area from the corridor,
and staff propping the door once the electrical mechanical door holder was removed, and corrective maintenance needs.
Corrective action taken immediately and documented; manager follow-up and staff education and accountability.
Other Areas Noted: Corrective action taken immediately and documented; not a trending issue.
EP, element of performance; AHU, air-handling unit ; OR, operating room; PACU, post-anesthesia care unit; IR, interventional
radiology; Endo, endoscopic; L&D, labor and delivery; ICU, intensive care unit; NICU, neonatal intensive care unit;
PM, performance maintenance.
14
FIGURE 1-3
DASHBOARDING SAMPLE—KPI SUMMARY
Environment of Care & Life Safety

Key Performance Indicators (KPIs) 1st Quarter 2nd Quarter 3rd Quarter 4th Quarter
Non- Non- Non- Non- Overall
Standard Description Compliant compliant Compliant compliant Compliant compliant Compliant compliant Compliant
The hospital manages risks associated with

EC.02.05.01 76.54% 23.46% 74.56% 25.44% 64.26% 35.74% 77.20% 22.80% 73.14%
its utility systems.
The hospital maintains the integrity of the means

LS.02.01.20 98.70% 1.30% 96.23% 3.77% 95.36% 4.64% 99.48% 0.52% 97.44%
of egress.
The hospital establishes and maintains a

EC.02.06.01 93.68% 6.32% 96.61% 3.39% 91.50% 8.50% 94.39% 5.61% 94.05%
safe, functional environment.
The hospital maintains fire safety equipment

EC.02.03.05 100.00% 0.00% 98.75% 1.25% 97.59% 2.41% 99.32% 0.68% 98.92%
and fire safety building features.
Building and fire protection features are

LS.02.01.10 designed and maintained to minimize the 96.40% 3.60% 98.72% 1.28% 95.33% 4.67% 98.72% 1.28% 97.29%
effects of fire, smoke, and heat.
The hospital provides and maintains building

LS.02.01.30 features to protect individuals from the 96.19% 3.81% 93.65% 6.35% 89.05% 10.95% 95.99% 4.01% 93.72%
hazards of fire and smoke.
The hospital provides and maintains

LS.02.01.35 93.68% 6.32% 96.61% 3.39% 91.50% 8.50% 94.39% 5.61% 94.05%
systems for extinguishing fires.
The hospital manages risks related to

EC.02.02.01 98.77% 1.23% 98.77% 1.23% 96.53% 3.47% 95.04% 4.96% 97.28%
hazardous materials and waste.
The hospital inspects, tests, and maintains

EC.02.05.09 100.00% 0.00% 99.35% 0.65% 100.00% 0.00% 98.93% 1.07% 99.57%
medical gas and vacuum systems.
The hospital inspects, tests, and maintains

EC.02.05.07 99.53% 0.47% 98.12% 1.88% 100.00% 0.00% 98.12% 1.88% 98.94%
emergency power systems.
Bolded standards are examples of noncompliance for an organization with a goal of 95% or greater.
Non- Environment of Careof Care

Environment Life Safety
Life Safety
Compliance compliance OverallOverall
Compliance
Compliance OverallOverall
Compliance
Compliance
Standard Percentage Percentage
6% 6% 4% 4%
EC.02.05.01
73.14% 26.86%
Utility Management
LS.02.01.20
97.44% 2.56%
Egress
EC.02.06.01
94.05% 5.96% 94% 94% 96% 96%
Safe & Functional Environment
EC.02.03.05
98.92% 1.09%
Fire Safety Equipment
LS.02.01.10 Compliance Percentage

Compliance Percentage Compliance Percentage
Compliance Percentage
97.29% 2.71%
Fire Safety Design
Noncompliance Percentage
Noncompliance Percentage Noncompliance Percentage
Noncompliance Percentage
LS.02.01.30
93.72% 6.28%
Fire Safety Maintenance
LS.02.01.35
94.05% 5.96%
Extinguishment
EC.02.02.01
97.28% 2.72%
Hazmat
EC.02.05.09
99.57% 0.43%
Medical Gas & Vacuum
EC.02.05.07
98.94% 1.06%
Emergency Power
Environment of Care 94.21% 5.79%
Life Safety 95.63% 4.38%
15
FIGURE 1-3
DASHBOARDING SAMPLE—KPI SUMMARY continued

Key Performance Indicator Dashboard
100.00%
Compliance
90.00%
Percentage 0.00%
Noncompliance
Percentage
80.00%
10.00%
70.00%
60.00%
20.00%
50.00%
30.00%
40.00%
30.00%
40.00%
20.00%
40.00%
10.00%
0.00%
50.00%
EC.02.05.01 LS.02.01.20 EC.02.06.01 EC.02.03.05 LS.02.01.10 LS.02.01.35 EC.02.05.09 EC.02.05.07
Utility Egress Safe & Fire Safety Fire Safety Extinguishment Medical Gas & Emergency
60.00%
Management Functional Equipment Design Vacuum Power
Environment
70.00%
80.00%
90.00%
100.00%
16
a normal shower rod in the patient’s room, and, that

Consequences of Not Performing Risk night, the patient hanged himself.
Assessments
If organizations do not perform risk assessments adequately, In addition to the horrific nature of the sentinel event
their inaction may lead to serious consequences, including itself, this lapse in risk management could result in
Occupational Safety and Health Administration (OSHA) Contingent Accreditation from The Joint Commission,
violations (see Sidebar 1-1 on page 19), a change in Joint and potentially make the organization vulnerable to
Commission accreditation status, adverse events and/or a lawsuit.
sentinel events*,1 or legal problems.
CONSIDER THIS… ■ Identifying Issues That Require a Risk

Assessment
A psychiatric patient commits suicide in his room one There are numerous means available to identify potential
night at a large medical center. The organization is problems or risks in organizations. The Joint Commission
stunned by the event because it has many processes
recommends that organizations use internal and external
and interventions in place to prevent such events.
sources to identify areas for risk assessment. These can
Examples of the facility’s processes and interventions
to minimize a patient’s risk of hanging include the include, but are not limited to, the following sources:
following:
• Internal performance improvement data
• Providing special linens, including shorter
• Staff feedback
towels—this limits a patient’s ability to create a
hanging risk by tying them together. • Patient and family feedback
• Environmental monitoring activities
• Accounting daily for all linens—this also limits
• Results of annual proactive risk assessments
a patient’s ability to create a hanging risk by
• Results of any root cause analysis (RCA) (see page 29 for
ensuring that the patient has not been given extra
linens or is “saving” linens. additional information on RCA)
• Data from sister, parent, or similar organizations on a
• Installing the following in patient rooms and on the
local or national level
floor to eliminate hanging risk:
• State or national professional organizations and
- Modified doorknobs
- Nurse call pull cords associations
- Breakaway shower rods • National safety organizations, such as ECRI Institute,
the Institute for Healthcare Improvement (IHI), and
In this case, the facilities engineer who maintains the
the National Patient Safety Foundation (NPSF)
psychiatric floor went on vacation, and the hospital
assigned a new engineer to that floor on a temporary • Government agencies
basis. However, the new engineer did not receive • Association/society/professional literature
training on the potential suicide risks associated • Sentinel Event Alerts and Sentinel Event Database
with psychiatric patients and the environmental • Liability insurance company
interventions and processes put in place to mitigate
those risks. The psychiatric department called engi- Where Does Risk Present?
neering to report that a shower rod broke in one of
Some areas and patient populations in health care organi-
the patient’s rooms and needed to be replaced.
zations are more prone to risk. These areas can represent
The temporary engineer did not know that only
breakaway shower rods are installed on the psych the primary places to start when considering possible risk
unit. Consequently, the temporary engineer installed assessments.
* Adverse events are patient safety events that result in harm to a patient.
Sentinel events are a subcategory of adverse events, and are those cases in CONSIDER THIS… ■
which an event, incident, or condition (not primarily related to the natural
course of the patient’s illness or underlying condition) reaches a patient
Due to its frantic pace, frequent patient turnover, acute
and results in death, permanent harm, or severe temporary harm. A list
of specific patient safety events that are also considered sentinel events
level of care, and constant access, the emergency
can be found in the “Sentinel Events” (SE) chapter of the Comprehensive department may be a location prime for risk in the areas
Accreditation Manual. of security, safety, and emergency management.
17
On the other hand, because of the large quantities To address this broader issue, a risk assessment
of chemicals and drugs stored there, the pharmacy would have to evaluate several locations for cabinetry,
may be at greater risk for issues associated with in addition to drawers, carts, tabletops, and so on.
hazardous materials and waste, as well as security.
The ICU and operating rooms may be more dramat- What The Joint Commission Requires
ically affected by utility failures and thus present Through the standards, The Joint Commission requires
higher risks that should be considered. organizations to conduct a variety of different risk assess-
ments and offers a number of recommendations for
Within specific patient populations, such as psychi- specific assessments. The most comprehensive of The
atric patients, risk may be considered higher because
Joint Commission’s required risk assessments is the
of the nature of their illnesses and the likelihood of
suicidal tendencies.
Intracycle Monitoring (ICM) process, which is part of the
Accreditation Participation Requirements (see Chapter
10 for a more detailed discussion of ICM). This compre-
Who Identifies Issues? hensive, online workspace guides organizations through
In a complex health care organization, the responsibility for accreditation compliance assessments and performance
deciding which issues should be targeted by an environment improvement activities between accreditation surveys. The
of care (EC) risk assessment can fall in a number of goal is to maintain consistent compliance throughout the
different places. Ultimately, the organization leadership accreditation cycle.
should identify the individual or individuals who will
assume responsibility for managing risk in the environment Joint Commission EC standards require that organizations
of care, including overseeing risk assessments. This person(s) have a process for assessing risks. Organizations also should
may come from a variety of different backgrounds, consider risks that could be organizationwide, department
including facilities management, public safety (security), specific, and/or issue specific. For example, Leadership
nursing, or risk management. As part of coordinating risk (LD) standards requires an organization to conduct not
management, the person(s) identified will work closely with less than one proactive risk assessment on a high-risk
other EC staff and organization leadership to identify which process a minimum of every 18 months. Additional EC
issues should be addressed by risk assessments. standards require preconstruction risk assessments for air
quality, infection control, utilities, noise, vibration, and
What Happens After Issues Are Identified? other hazards associated with a demolition, construction,
After identifying an issue to be targeted by an EC risk or renovation project. Infection Prevention and Control
assessment, it is important to frame the assessment in the (IC) standards require organizations to identify and plan
right way. The issue should be specific and straightforward, for risks for acquiring and transmitting infections. These are
and phrased as a yes/no question whenever possible. only a few examples of risk-assessment requirements, and
Combining several issues, even if they are related, can cause not an exhaustive list.
confusion and result in faulty conclusions. An issue that is
too broad will quickly become too complicated—or too Documentation
vague—to be useful. The Joint Commission requires documentation for many of
the previously mentioned risk assessments. The form that
CONSIDER THIS… ■ documentation takes may vary, but the general rule is “not
documented, not done.” In other words, documentation is
The following statement is a strongly phrased issue. proof that a risk assessment was actually performed.
It is specific and easy to understand. Ultimately, the Elements of performance (EPs) that require documentation
result will be a clear-cut, yes or no answer.
are identified with a icon in the Comprehensive
“Can we store items under the sink in patient care Accreditation Manual.
areas?”
As opposed to the following open-ended statement: If in doubt, document. This is a good rule to observe
because documentation has benefits beyond complying
“Where can we store things in patient care areas?”
18
SIDEBAR 1-1 Willful violations

Employers that intentionally disregard OSHA regulations
Complying with OSHA or show a plain indifference to employee safety and
health will be cited for willful violation. In these cases,
The Occupational Safety and Health Administration employers are aware a hazardous condition exists and
(OSHA) is a federal agency that aims to ensure employee make no reasonable effort to eliminate it. Penalties for
safety and health in the United States by working with willful violation can be proposed to be as much as
employers and employees to create better working $70,000 per citation, with the minimum penalty being
environments. Its mission is to prevent work-related $5,000. Proposed penalties may be adjusted downward;
injuries, illnesses, and deaths. OSHA has a series of however, no credit typically is given for good faith.
regulations that organizations must follow to ensure
employee safety and health. Failure to comply with Employers convicted of a willful violation that resulted in
OSHA’s regulations may result in the following violations. the death of an employee may be fined as much as
$250,000 ($500,000 if the employer is a corporation) or
Types of OSHA Violations imprisoned for no more than six months, or both.
Citations for failure to comply with OSHA’s regulations Additional convictions may increase the term of
vary based on the likelihood the hazardous condition will imprisonment.
result in serious physical harm or death, as well as the
employer’s intent to actively seek a solution for or willfully Repeat violations
disregarding the hazardous condition. Penalties for an Such citations occur when a violation of any standard,
employer can be equally varied, including not more than regulation, rule, or order where, upon reinspection, a
six months’ imprisonment and a $250,000 fine. substantially similar violation is found. In these cases, the
original citation becomes a final order and a penalty of as
Other-than-serious violations much as $70,000 per violation may be ordered.
OSHA classifies these violations as having a direct
relationship to job safety and health but are not serious in Failure to abate prior violations
nature. Violations under this classification are not A civil penalty of as much as $7,000 per day may be
considered life threatening, and the risk of serious leveled when an employer fails to correct a prior violation.
physical harm is minimal. The penalty will be applied when the violation continues
beyond the prescribed abatement date.
The proposed penalty of as much as $7,000 per violation
is discretionary. Violations classified as “other-than-se- Additional violations
rious” may be adjusted downward depending on factors In addition to the previously listed violations, OSHA may
such as demonstrated compliance efforts, previous cite employers for the following actions:
inspection history, and business size. • Falsifying records, reports, or applications. Penalties
Serious violations include the potential for a criminal fine of not more than
Workplace hazards that have a high probability of causing $10,000 or a six-month imprisonment, or both.
an accident or illness resulting in death or serious • Violating posting requirements. Penalties include a fine
physical harm are classified as “serious” violations. In of $7,000.
these situations, the violation is cited when an employer
knew or should have known of the hazard and its • Assaulting a compliance officer or otherwise impeding
resulting consequences. a compliance officer’s performance of duties.
Penalties for this criminal offence include a fine of
As with other-than-serious violations, OSHA may propose not more than $5,000 and an imprisonment of not
a penalty as much as $7,000 per violation. These more than three years.
violations may be adjusted downward depending on the
severity of the violation, demonstrated compliance efforts,
previous inspection history, business size, and so on.
Sources
1. Safety News Alert. Types of OSHA Violations. Accessed Sep 7, 2015. http://www.safetynewsalert.com/types-of-osha-violations.
2. US Department of Labor, Occupational Health and Safety Administration. OSHA Inspections. OSHA Publication 2098. 2002.
Accessed Sep 7, 2015. https://www.osha.gov/Publications/osha2098.pdf.
19
with standards. Documenting is extremely useful during the Types of EC Risk Assessments
risk-assessment process because it helps establish the steps The following sections offer a brief description of the
involved in the risk assessment and records the results in a various risk assessments that will be explored in greater
consistent manner. In addition, documenting aids in detail throughout this book. Many are contained within the
maintaining consistency throughout the risk-assessment EC chapter of the Comprehensive Accreditation Manual,
process, so that every time a particular type of risk assess- while other assessments fall under different standards
ment is conducted—such as a job hazard analysis (JHA) chapters in the manual. This list is a brief introduction to
or a medical equipment inventory—it is completed the some of the more common assessments; more information
same way. (See Figure 1-4 beginning on page 21 for a will be contained in Chapters 2 through 9.
documentation checklist.)
Safety Risk Assessments
CONSIDER THIS… ■ Safety risk assessments (see Chapter 2) address safety issues
associated with the physical environment (such as falls on a
Risk assessment documentation also can be used to wet floor) and the behavior of people being served (such as
illustrate an organization’s work on a particular issue. workplace violence). They include environmental tours and
For example, a surveyor is assessing compliance
worker safety analyses, as well as risk assessments resulting
during an on-site survey and notes a questionable
from the ongoing monitoring of the environment, RCAs,
procedure—storing sharps at the bedside. By
providing supportive documentation to the surveyor, annual proactive risk assessments of high-risk processes, and
the organization can demonstrate that a proactive Sentinel Event Alerts.
risk assessment was conducted and considered the
possible hazards associated with the issue. By Hazardous Materials and Waste Assessment
providing this documentation, the organization can Through a hazardous materials and waste assessment (see
prove that it conducted risk-assessment work Chapter 3), organizations identify materials that require
regarding storing sharps at the bedside, thus allowing
special handling and implement processes to minimize the
the surveyor to feel more comfortable with the
risks of their unsafe use and improper storage and disposal.
organization’s decision.
These assessments typically take the form of inventories of
all potentially hazardous chemicals within the organization.
Risk assessments can be documented in a variety of ways.
They can be completed using established forms or spread- Security Risk Assessment
sheets that organizations create, like one often used in the Organizations perform a security risk assessment (see
hazard vulnerability analysis (HVA) process (see Chapter 8 Chapter 4) to identify any security risks that may be present
for more information on HVA). Or the assessment can be in the environment, as well as risks to patient, staff, and
documented by simply drawing a line down the middle of a visitor security throughout the organization. Examples of
piece of paper and listing the pros of a project or process on security risks include elopement from a psychiatric unit,
one side and the cons on the other. The method chosen will infant abduction from the obstetrics ward, or domestic
depend on the particular situation and organization. violence in a home care residence.
Although The Joint Commission does not always require Fire and Life Safety
a specific form of documentation, it does require organiza- Several different assessments are required to ensure that
tions to follow their own policies. So if organizations have fire and life safety risks (see Chapter 5) are minimized. The
risk-assessment policies that include specific documenta- Statement of Conditions™ (SOC) helps organizations iden-
tion, The Joint Commission requires that those policies be tify and plan for effective fire response, specifically through
followed and that documentation be used. Consequently, compliance with the National Fire Protection Association’s
organizations should make sure that their developed docu- (NFPA) Life Safety Code®.† Only those health care orga-
mentation systems are used appropriately and consistently. nizations that are classified as health care, ambulatory, or
®
† Life Safety Code is a registered trademark of the National Fire
Protection Association, Quincy, MA.
20
FIGURE 1-4
EC Frequency Documentation Checklist
The Joint Commission requires that certain activities be performed to help manage the environment of care (EC). This grid shows
how frequently these activities must be performed. Use it to help keep track of and document your performance of these items.
Requirement Frequency Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Comments
Fire Drills
Ambulatory
Quarterly
Occupancy
Business
12 Months
Occupancy 1
Business
12 Months
Occupancy 2
Business
12 Months
Occupancy 3
Hospital Quarterly
Quarterly
Residential for 24-Hour
Care
Fire Safety Equipment and Building Features
Fire Alarm System*
A/V Devices 12 Months
AHU Shutdown 12 Months
Alarm Signal
Transmission
Quarterly
to Off-Site
Responders
Duct Detectors 12 Months
Electromechanical
12 Months
Releases
Heat Detectors 12 Months
Pull Stations 12 Months
Sliding and
12 Months
Rolling Fire Doors
Smoke Detectors 12 Months
Supervisory
Quarterly
Signals
Semi-
Tamper Switches
Annually
Water Flow
Quarterly
Switches
Fire Sprinkler and Suppression Systems
Carbon Dioxide/
12 Months
Gaseous Systems
Fire Department
Quarterly
Connections
Fire Pump—Flow 12 Months
Fire Pump—No
Weekly
Flow
21
FIGURE 1-4
EC Frequency Documentation Checklist continued
Kitchen Hoods
Semi-
• Duct Cleaning
Annually
• Fire Suppression Semi-
Inspection Annually
Semi-
• Systems
Annually
Main Drain Test 12 Months
Standpipe Flow 5 Years
May replace
every 5
5 Years/ years in lieu
Standpipe Hoses
3 Years of 3-year
hydrostatic
test
Storage Tank Semi-
Hi-Lo Level Alarm Annually
Storage Tank
Temperature Monthly†
Alarm
Fire Extinguishers
Ambulatory Monthly/
Occupancy 12 Months
Business Monthly/
Occupancy 1 12 Months
Business Monthly/
Business Monthly/
Monthly/
Hospital
12 Months
Monthly/
Residential
12 Months
Smoke/Fire Dampers
Ambulatory Every Year/
Occupancy 4 Years
Business Every Year/
Occupancy 1 4 Years
Business Every Year/
Occupancy 2 4 Years
Every Year/
Hospital
6 Years
Medical Equipment Maintenance
CT 12 Months
Dialysis Water
As Defined
Testing
High-Risk As Defined
MRI 12 Months
NM 12 Months
22
FIGURE 1-4
EC Frequency Documentation Checklist continued
Non–High-Risk As Defined
Medical
PET 12 Months
Sterilizers As Defined
Utility Systems Maintenance
High-Risk As Defined
Infection Control As Defined
Non–High-Risk As Defined
Emergency Power Systems
Battery-Powered Emergency Lights
Ambulatory Monthly/
Occupancy 12 Months
Business Monthly/
Business Monthly/
Business Monthly/
Monthly/
Hospital 12 Months
Monthly/
Residential 12 Months
SEPSS
Quarterly/
SEPSS
12 Months
Generator System
Monthly &
ATS (each) Maintenance
Reqs
Load Test 12 Monthsǂ
Every
Four-Hour Test
3 Years
Medical Gas Systems
Master Alarm
As Defined
Panels
Area Alarm
As Defined
Panels
Auto Pressure
As Defined
Switches
Shutoff Valves As Defined
Flexible
As Defined
Connectors
Outlets As Defined
* The settings are not listed here because the environment of care is not occupancy specific, and if an organization has the components, it must maintain them.
† Denotes cold-weather testing only.
ǂ
Test annually if not meeting monthly 30% of load.
A/V, audio/visual; AHU, air-handling unit; ATS, automatic transfer switch ; CT, computed tomography; MRI, magnetic resonance imaging; NM, nuclear medicine; PET,
positron emission tomography; SEPSS, stored emergency power supply systems
23
residential occupancies must complete an SOC (see Chapter assessment before the process of renovating, altering, or
5 for additional information on determining occupancy newly creating spaces in order to identify hazards that could
type). When deficiencies in Life Safety Code compliance potentially compromise care, treatment, and services in
are found using the SOC, organizations must implement occupied areas of the organizations’ buildings. The scope
interim life safety measures (ILSM) to temporarily and nature of the construction activities determine the
compensate for the identified fire safety risks. extent of risk assessment, but should address all risk areas
(for example, safety, fire and life safety, utilities). In addition,
Medical Equipment Risk Assessment the PCRA must include a specific infection control risk
The Joint Commission requires organizations to manage assessment (ICRA) to manage construction-related infection
the risks associated with medical equipment (see Chapter risks, such as air and water quality and mold mitigation.
6). To do this, organizations must establish a risk-assess-
ment process to identify, evaluate, and create an inventory Methods Used to Conduct Risk Assessments
of equipment. This inventory must address equipment Although The Joint Commission recommends and requires
function and the physical risks associated with the equip- many different risk assessments, the standards do not
ment’s use. Organizations also must have plans to address address all the possible risks found in health care organiza-
risks associated with failure of medical equipment, tions. It is almost guaranteed that staff will encounter issues
including the timely replacement of equipment when that or problems in which a proactive risk-assessment process
equipment is life sustaining. may be necessary, yet a requirement does not specifically
exist for it according to the Joint Commission standards.
Utility Risk Assessment For example, in the previous discussion about storing
Similar to medical equipment risk assessment, organizations sharps near the bedside in the ICU, the issue does not
must engage a risk-assessment process to ensure the have a direct standard associated with it, and no required
operational reliability of utility systems (see Chapter 7) and risk assessment would address it, yet the safety manager
identify and respond to risks. Utility systems are defined as conducted a risk assessment to ascertain the risks associated
those that provide support to the environment of care, with storing sharps at the bedside.
including electrical distribution and emergency power;
vertical and horizontal transport; heating, ventilating, and It is beneficial in these types of situations to have a stan-
air conditioning (HVAC); plumbing, boiler, and steam; dardized approach to assessing risk proactively. This
piped gases; vacuum systems; and communications, approach should be applicable to organizationwide,
including data exchange systems.1 Organizations also must department-specific, and issue-specific assessments and
have contingency plans in place that address risks associated should be used to evaluate the gray areas in the health care
with utility failures, such as an interruption in any utility environment—that is, issues for which there is no definitive
service due to construction, natural disaster, or other cause. right or wrong answer. The following sections describe
several types of assessment processes that can be used to
Emergency Management address many kinds of risks.
One of the primary risk assessments used in emergency
management (see Chapter 8) is an HVA. This assessment Simple Proactive Risk Assessment
helps organizations identify potential threats that may Although a proactive risk assessment will vary for each
impact the environment, mitigate potential risks, and health care organization, the following is a basic approach
develop effective and comprehensive Emergency Operations organizations can consider using (see Figure 1-5 on page 25
Plans. An HVA may address such threats as natural disasters, and Figure 1-6 beginning on page 26, for a visual represen-
chemical spills, terrorist acts, and influenza pandemics. tation of these steps and a sample worksheet, respectively).
Construction Before embarking on this process, an organization may

Before any demolition, construction, or renovation project, want to pull together a team of individuals who are familiar
organizations must perform a preconstruction risk assess- with the many aspects of the issue in order to obtain the
ment (PCRA) (see Chapter 9). Organizations conduct this most comprehensive definition. These stakeholders should
24
FIGURE 1-5
RISK-ASSESSMENT CYCLE
1
Identify Issue
7 2
Monitor Advantages
and Reassess
6 3
Document Disadvantages
5
Reach a
Conclusion 4
Objectively
Evaluate
This diagram illustrates the seven basic steps of a simple risk-assessment process.
represent a variety of perspectives to ensure an unbiased Arguments in favor of under-sink storage might include the
analysis of the issue (see Sidebar 1-2 on page 27). following:
Steps Involved in Simple Assessments • Easy access

Step 1: Identify the issue. Clearly define the issue under • Relieving crowding in other storage areas
study. The issue defined becomes the focus of the risk
assessment. As previously stated, it is important to avoid Step 3: Develop arguments that disagree with the
combining several issues in one risk assessment, or the proposed process or issue. These arguments may be
process could become complicated and confusing. perceived concerns or situations that may pose potential
risks or impact a situation negatively. It may be helpful to
Identified issue: “Can we store items under the sink in patient use the same questions in Step 2, with a response column
care areas?” for disadvantages.
Step 2: Develop arguments that support the proposed Arguments against under-sink storage might include the
process or issue. After the issue is identified clearly, develop following:
arguments that support the proposed process or issue. It
may be helpful to create a columned list of questions, with • Potential damage to items from leaking faucets
a response column for advantages. Answers should reflect • Infection risk from damp paper items
the specific needs of the affected patient population. • Potential for mold growth
25
FIGURE 1-6
PROACTIVE RISK-ASSESSMENT WORKSHEET
Proactive Risk Assessment

Describe the issue:
Those involved in the discussion:
Arguments
SUPPORTING ARGUMENTS OPPOSING ARGUMENTS

(Why should the issue remain the same?) (Why should the issue be changed?)
Any applicable risk reports or performance improvement data?
Any applicable Sentinel Event Alerts?
Any additional applicable codes, regulations, and/or guidelines?
Mitigation: (potential strategies to reduce risk)
Approved for implementation? ■ Yes ■ No

Conclusion:
Communication plan:
Time frame for reassessment (if applicable): Date(s) for reassessment:
Person(s) responsible for follow-up (if applicable):
Route to Risk Manager/QI

Name: Date:
26
SIDEBAR 1-2
risk assessment to a multidisciplinary committee, such
Assembling a Team as the safety committee or a performance improvement
committee, to secure organizational consensus regarding
In some cases, it may be appropriate to assemble a this conclusion.
multidisciplinary team to conduct the risk-assessment
process. This allows multiple perspectives on an issue
The evaluation team reaches a consensus to allow storage of
and can ensure the most comprehensive assessment.
only non–patient care items, such as flower vases, under sinks
Selection of team members is critical. Team members in patient care areas.
should bring to the table a diverse mix of knowledge
bases and should be knowledgeable about and
Step 6: Document the process. Documentation could
committed to performance improvement, as well as
include the risk-assessment worksheet, a written discussion
safety. The team should include individuals with funda-
mental knowledge of the particular process involved. of the issue in the minutes of the safety committee (or other
These are the subject matter or process experts. The committee) meeting, or a formal report. At this point, any
team also should include representatives from areas that relevant policies should be updated to reflect the conclusions.
may be affected directly by changes in the process.
These individuals will be the ones most impacted by The team provides the safety committee with a copy of the
changes and will have the most at stake during the risk-assessment worksheet. The risk assessment is documented
redesign.
in the minutes of the safety committee meeting, and the storage
The team also might include an individual with some policy is amended to reflect the decision to allow non–patient
distance from the process—perhaps one who is not at all care items to be stored under the sink in patient care areas.
familiar with the process—but who possesses excellent Staff is informed of the new policy during regular meetings.
analytical skills. Functioning perhaps as an advisor or
facilitator, this person can provide a fresh perspective,
Step 7: Monitor and reassess the conclusion to ensure
unencumbered by the classic “that’s how we’ve always
done it” mentality. At least one individual with decision- that it is the best decision. A monitoring strategy should
making authority (a leader) and individuals critical to the be decided on from the beginning and be included in the
implementation of anticipated process changes are risk-assessment document that is submitted to the safety
needed as well. committee or performance improvement committee. The
strategy should include a specific date to reassess the
conclusion drawn by the risk assessment. If the reassessment
Step 4: Objectively evaluate both arguments. It is crucial determines that an unintended effect or incorrect conclusion
that the organization conduct an impartial comparison was reached, the issue is submitted to the multidisciplinary
of the advantages and disadvantages associated with the committee for reassessment. However, if the evaluation
issue. Pros and cons must be thoroughly examined by all confirms the conclusion, then the confirmation is docu-
stakeholders—which requires pulling together the right mented and the benefits of further monitoring are decided.
individuals who can access the relevant information. Some
elements to consider in this evaluation include patient After three months, the under-sink storage issue is revisited.
population, state and local laws and regulations, and inci- It is found that both patient care items and non–patient care
dent reports and history. items are being stored together under some sinks—a situation
not allowed by the risk-assessment conclusion. It is decided that
The pros and cons of storing items under the sink are the effect was unintended, and the issue is resubmitted to the
evaluated by representatives from infection control, facilities risk-assessment team for review.
management, nursing, and administration.
Failure Mode and Effects Analysis
Step 5: Reach a conclusion. The evaluation should result When conducting risk assessments on complex issues,
in a decision to accept the risk and make no changes, organizations may need to use more than just a simple
or to take steps to avoid or mitigate the risk. When the proactive risk assessment. Failure mode and effects analysis
conclusion is determined, it is advisable to submit the (FMEA) is a tool that can help an organization examine a
27
high-risk process. This team-based, systematic technique is • What tools should be used to diagram the process?
used to prevent problems before they occur. FMEA • What is the manner in which this process could fail?
provides a look not only at what problems could occur but - When answering this question, team members should
also examines how severe the effects of the problems could consider how people, materials, equipment, processes
be. It assumes that no matter how knowledgeable or careful and procedures, and the environment affect the
people are, failures will occur in some situations and may process.
even be likely to occur. The focus is on what could allow • What are the potential effects of the identified failures?
the failure to occur, rather than who. - Effects of failures might be direct or indirect, long
term or short term, or likely or unlikely to occur. The
Ideally, FMEA is used to help prevent failures from occur- severity of effects can vary considerably, from minor
ring. However, if a particular failure cannot be prevented, annoyances to death or permanent loss of function.
FMEA then focuses on protections that prevent the failure In this part of the process, team members should
from reaching the patient, or, in the worst case, mitigate the think through all the possible effects of a failure and
failure’s effects if it reaches the patient. list them for reference.
• What are the root causes of prioritized failure modes?
The Steps Involved in FMEA - What would have to go wrong for a failure like this
The FMEA technique is based on studied engineering to happen?
principles and approaches to designing systems and - What underlying weaknesses in the system might
processes. It has been used successfully in a number of allow this to happen?
industries, including the airline, automotive, and aerospace - What safeguards (for example, double checks) are
industries. Varying by the source consulted, FMEA can present in the process?
involve as few as 4 or as many as 10 steps. - Are any missing?
- If the process already contains safeguards, why might
The case study, beginning on page 31, provides a real-life they not work to prevent the failure every time?
scenario using a 7-step, risk-assessment process. The - If this failure occurred, why would the problem not
approach used includes these 7 key steps: be identified before it affected a patient?
1. Define the issue. After the team has identified root causes and determined
2. Assess benefits. any intolerable potential effects of the process, the team
3. Assess risks. devises and implements actions to eliminate the possibility
4. Evaluate the scores. of error, stop an error before it reaches patients, or mini-
5. Reach a conclusion. mize the consequences of an error. Then the team reviews
6. Document the results. and revises, as necessary, the action or actions being taken
7. Monitor and reassess. or planned to minimize the probability or effect of failure.
Questions Involved in FMEA Comprehensive Systematic Analysis

When conducting an FMEA on a complex process, teams Another useful tool for assessing risk is a comprehensive
should answer the following questions: systematic analysis. The Joint Commission requires
organizations to conduct a comprehensive systematic
• What are the steps in the process? analysis in response to sentinel events (as defined in the
- If it is an existing process, how does it currently occur “Sentinel Events” [SE] chapter of the Comprehensive
and how should it occur? Accreditation Manual).
- If it is a new process, how should it occur?
• How are the steps interrelated? Although there are several methods of conducting a
- For example, are they sequential or do they occur comprehensive systematic analysis, the most common is an
simultaneously? RCA (root cause analysis). This is a process for identifying
• How is the process related to other health care processes? the basic or causal factors that underlie variations in
28
performance. Variations in performance can (and often do) “defects.” A defect is defined as nonconformity of a
produce unexpected and undesired adverse outcomes, product or service to its specifications. Six Sigma asserts
including the occurrence or risk of an adverse event or a that processes can be measured, analyzed, improved, and
sentinel event. controlled, and that continuous efforts to reduce variation
in process outputs are key to success.
Similar to an FMEA, an RCA focuses primarily on systems
and processes, not on the performance of a particular Steps Involved in Six Sigma Methodology
individual. Through an RCA, a team works to understand Six Sigma has two key methodologies.
a process or processes, the causes or potential causes of vari-
ation, and process changes that make variation less likely to 1. Define–Measure–Improve–Analyze–Control
occur in the future. An RCA most commonly is used reac- (DMAIC)—used to improve an existing process (see
tively to probe the reason for a bad outcome or for failures Figure 1-7 on page 30)
that already have occurred. It also can be used to probe a 2. Define–Measure–Analyze–Design–Verify (DMADV)—
near-miss event or as part of the FMEA process. used to create new process designs for predictable,
defect-free performance (see Figure 1-8 on page 30)
Steps Involved in an RCA
A thorough and credible RCA has several steps. Many of In recent years, Six Sigma ideas have been blended with
the steps involved in an RCA are similar to an FMEA: Lean manufacturing concepts to create the Lean Six Sigma
methodology. It aims to eliminate waste in product, work
• Organize a team. flow, time, and other areas.
• Define the problem.
• Study the problem. More information about Six Sigma can be found at http://
• Determine what happened. www.ihi.org.
• Identify the contributing factors.
• Collect and assess data on proximate and The Risk-Assessment Cycle
underlying causes. To be effective, a risk assessment cannot be conducted just
• Design and implement interim changes. to check another box on the compliance list, done once
• Determine the root causes. and forgotten. Risk assessments should be used as active
• Explore and identify risk-reduction strategies. learning and improvement tools. Organizations must take
• Evaluate proposed actions. the information gleaned from a risk assessment and respond
• Design, test, and implement improvements. to it. This response may involve changing a process,
• Evaluate and communicate the results of improvements. introducing a new process, or planning for reassessment
A template for conducting an RCA can be found at to determine the volatility of a process. The response also
http://www.jointcommission.org/Framework_for_ could be a deliberate decision to take no immediate action,
Conducting_a_Root_Cause_Analysis_and_Action_Plan/. but to monitor the situation after a predetermined amount
of time.
Six Sigma
Six Sigma is another approach to risk assessment and New risks arise every day in the health care environment,
performance improvement. Originally designed by and the potential hazards associated with health care
Motorola, it can be used by any organization to imple- delivery can emerge and change quickly. Organizations
ment new processes or redesign existing ones. Six Sigma should plan to assess and respond to risks continually and
approaches systematic process improvement by eliminating to determine the nature and frequency of reassessments.
Reference
1. The Joint Commission. 2016 Comprehensive Accreditation Manual for Hospitals. Oak Brook, IL: Joint Commission
Resources, 2015.
29
FIGURE 1-7
DMAIC METHODOLOGY
DEFINE MEASURE ANALYZE IMPROVE CONTROL

• Define the process • Measure the current • Analyze to verify • Improve or optimize • Control to ensure that
improvement goals. process and collect the relationship and the process based on any variances are
relevant data for future causality of factors. the analysis. corrected before they
comparison. • Determine what the result in defects.
relation is and attempt
to ensure that all
factors have been
considered.
Using the DMAIC methodology will help improve an existing process for an organization.
FIGURE 1-8
DMADV METHODOLOGY
DEFINE MEASURE ANALYZE DESIGN VERIFY

• Define the goals of the • Measure and identify • Analyze to develop • Design details, • Verify the design,
design activity. critical qualities, and design optimize the design, set up pilot runs,
process capabilities, alternatives, create and plan for design implement the
and risk assessments. high-level design, verification. process, and hand
and evaluate design • This step may require over to process
capability to select the simulations. owners.
best design.
To create new process designs, organizations may use the DMADV methodology.
30
■ CASE STUDY: Storage of Endoscope Supplies
Risk assessments take a variety of forms. In some cases, Next, the current and alternative situations must be
it can be as simple as spending an hour considering the stated simply and clearly. In this case, the current
issue in a straightforward, structured way. situation was that endoscope supplies containing sharps
were kept on shelves in an unlocked limited-access
UW Health, an academic health system associated with (restricted) procedure room. The alternative condition,
the University of Wisconsin–Madison that includes or proposed change, would be to keep endoscope
the University of Wisconsin Hospitals and Clinics, supplies containing sharps in a locked drawer in that
uses a seven-step risk assessment that was adapted and same limited-access procedure room.
modified from an assessment process created by The
Joint Commission. The assessment can be used when- “It’s important to keep the focus as specific as possible,”
ever a clinical area is making a decision between two says Smith-Helmenstine. “If it’s too broad, it becomes
processes. Generally, this is between a current process very complicated very quickly. Broad issues are best
and a new alternative; however, it also could be used handled by multiple risk assessments.”
when deciding between two new processes.
The final piece in defining the issue is the scope of the
“This risk assessment has proven to be quite a valuable impact. Some risk assessments affect the entire organi-
tool,” says Jackie Smith-Helmenstine, senior quality zation or facility, while others affect only a single floor,
analyst, regulation and accreditation coordinator for department, or room. In this case, the risk was limited
UW Health. “It helps staff come up with a quantitative to two procedure rooms in one outpatient facility.
score that supports decision making.”
Steps 2 and 3: Assess Benefits and Risks
About the Project These steps look at a range of topics that may be affected
The staff at one of UW Health’s ambulatory facilities by the process in question. Such topics include patient
was concerned with its storage of endoscope supplies. safety, patient satisfaction, quality of care, environment
At this location, endoscope supplies that contain sharps of care, budget, and work flow, among others. Each
were being kept in unlocked cabinets in limited-access topic is discussed individually for both the current
procedure rooms. Staff were unsure whether this posed situation and the proposed alternative, and respective
a risk to patient or visitor safety. They decided to do a benefits and risks are assigned a number value.
risk assessment to determine whether these particular
endoscope supplies should be kept in a locked storage UW Health uses the following scoring system:
cabinet. (See Figure 1-9 beginning on page 34 for the
form used to illustrate this seven-step process.) • 5 = high
• 3 = moderate
Step 1: Define the Issue • 1 = low
The first step is to define the issue that will be assessed • 0 = not applicable
for risk. This includes several areas of information.
First, the participants and/or stakeholders should be Smith-Helmenstine says this system sharpens the
identified. These might include the individuals who distinction between the scores, forcing the team to
work in and oversee the department or area being make strong decisions and eliminating the “gray areas.”
assessed. It also should include a strong facilitator,
according to Smith-Helmenstine. This person is Step 2 focuses on the current situation—in this case,
responsible for guiding the group through the assess- storing the endoscopic sharps in unlocked cabinets in
ment process and keeping it on task. the limited access area. The team goes down the list of
31
■ CASE STUDY
STUDY: Storage
continued
of Endoscope Supplies continued
topics and first considers the benefits, then the risks, benefits far outweighed the risks. The alternative,
associated with each. locking the sharps, had risks (34) outweighing the
benefits (9).
For example, what is the benefit to patient safety of
keeping these sharps unlocked? Discussion revealed Another way to evaluate the scores is to compare the
that patient safety was increased by unlocked sharps benefit of the current situation to the benefit of the
because staff could quickly and easily access needed alternative, and the risk of the current situation to the
supplies. The group gave this a 5, or high, score. Then risk of the alternative. Again, in this case, the benefit
what is the risk to patient safety of keeping these of keeping the sharps unlocked was much greater than
sharps unlocked? The team determined that because locking them up, while the risk was the inverse.
the sharps were stored in a limited-access area, the risk
to patient safety from keeping them unlocked was For this particular risk assessment, the numbers gave
minimal. This was scored as 1, or low. a very clear picture. This may not be the case for all
situations. If the scores are close, the team may wish
Step 3 follows the same process as Step 2, only this to look at the individual topics and weigh their impor-
time focusing on the alternative situation (that is, tance based on the particular situation. For example,
locking up the sharps). When assessing patient satisfac- work flow and budget may be the primary concerns,
tion, the team determined that locking sharps would and those scores could be considered directly.
have minimal benefit but may create moderate risk, as
the procedure length and wait time increases. Step 5: Reach a Conclusion
This is the part of the assessment in which a decision
Not all topics will necessarily apply to all risk is made to either continue the current practice or
assessments. In this case, the safety to the environ- implement the alternative. Smith-Helmenstine empha-
ment—that is, prevention of damage to the physical sizes that this assessment is only one tool used to inform
structures—was not an issue, and was scored as 0. a decision. In this case, the team decided the results
were overwhelmingly in favor of keeping the sharps
Smith-Helmenstine says the facilitator should unlocked, and recommended that the practice continue.
encourage the group to come to consensus quickly.
This avoids overthinking the issues, and increases Step 6: Document the Results
efficiency. In this case, the team was able to complete This is the part of the assessment in which the results
the assessment in just over an hour. and recommendation are reported to the appropriate
committee, according to organizational policy.
Step 4: Evaluate the Scores Sometimes, if the issue is complex or wide in scope or
Now it is time to add up scores for each column: impact, the safety committee or other body of
current situation benefits, current situation risks, authority will need to review the assessment before any
alternative situation benefits, and alternative situation action is taken. In other situations, that may not be
risks. The resulting numbers can be evaluated to see if necessary. In the example described here, the scope was
an overall picture emerges. The numbers can be limited to two rooms in one building, and no changes
evaluated from several perspectives. First, the current were being recommended. Therefore, the team leader-
situation’s overall benefit can be compared to its overall ship did not require formal review or approval from the
risk, and the same for the alternative situation. In this safety committee.
case, keeping the sharps unlocked had a benefit scored
at 34, while the risk of this practice scored a 10—the
32
■■ CASE
CASESTUDY
STUDY Storage
STUDY: continued
of Endoscope Supplies continued
“It’s helpful to have someone on the risk assessment including the responsible parties for each process,
team who either has the authority to approve changes should be determined as part of the original assessment.
or can access someone with that authority,” says In a simple risk assessment, such as this example, the
Smith-Helmenstine. “This can keep the process from monitoring can be as easy as checking back after a few
becoming unnecessarily complicated.” months to inquire if there have been any safety events
related to endoscope supplies. If the answer is “no,”
Step 7: Monitor and Reassess document your follow-up, and your risk assessment
A monitoring strategy and time line for reassessment, is complete.
33
FIGURE 1-9
SAMPLE SEVEN-STEP RISK-ASSESSMENT WORKSHEET

DATE: 5/1/2015 FACILITATORS: Jackie Smith-Helmenstine, Lisa LeClair
PARTICIPANT(S)/STAKEHOLDER(S): Anne Rikkers, Denise Leroy, Brittany Nesbit, Jackie Stubbe
STEP 1A CURRENT ISSUE/CONDITION: Scope supplies with sharps kept unlocked in limited (restricted)
access area in procedure rooms
STEP 1B ALTERNATIVE CONDITION/PROPOSED CHANGE: Scope supplies containing sharps locked in drawer
in limited access area in procedure rooms
STEP 1C LOCATION OF CURRENT ISSUE/CONDITION:
□
INPATIENT UNIT □X OUTPATIENT AREA: □ HOUSEWIDE □ ED □ OTHER:
Digestive Health Center
Endoscopy
STEPS 2 & 3 ASSESS BENEFITS VS. RISKS KEY: Low – 1 Moderate – 3 High – 5 NA – 0
Perspective► 1a Current Issue/Condition 1b Alternative Condition/Proposed Change

Discussion Topics▼ Benefit Risk Rationale/Examples Benefit Risk Rationale/Examples
Patient safety 5 1 Removing barriers to access. 1 5 Adding barriers to supplies.
Benefit pertaining to the scope
supply sharps is minimal. Airway
supplies covered by sharps.
Patient satisfaction 3 1 Procedure length is shorter when 1 3 Patient sees secure environment.
access isn’t restricted. Patient experiences wait time for
staff to attain supplies.
Outcome (quality) of 5 1 Able to get to supplies quickly. 1 5

patient care Airway supplies not covered or
impacted by locked sharps.
Staff and volunteer 3 1 1 3 Pinched fingers, hit head, throw

safety out back.
Staff and volunteer 5 1 Techs can function independently 1 5 Limited access to supplies and
satisfaction and readily access needed tools needed to care for patients.
supplies.
Visitor safety 1 1 1 1
Visitor satisfaction 3 1 Visitors/family not waiting for 1 3 Limiting time visitors are waiting
patients. for patients.
Environment safety, 0 0 0 0
including building
and grounds
Financial operation, 3 1 Less staffing, no badge access. 1 3 Losing keys, badge access
budget readers, staffing requirements.
Work flow efficiency 5 1 Allowing tech to independently 0 5 Access to supplies limited and
retrieve supplies. extends length of procedures.
Compliance with 1 1 No contradiction in policy, no direct 1 1
regulatory requirements regulation for sharps storage.
34
FIGURE 1-9
SAMPLE SEVEN-STEP RISK-ASSESSMENT WORKSHEET continued

STEP 4 Evaluate the Discussion Topics
Perspective▼ Score► Benefit Risk Perspective▼ Score► Benefit Risk

Assess Impact of Current Issue/ Assess Impact of Alternative Condition/
34 10 9 34
Condition On Proposed Change
DISCUSSION POINTS: Current condition benefit far outweighs risk. The alternative risk far outweighs the benefit. The benefit
of current condition outweighs the benefit of the alternative. The risk of the current condition is much
less than the risk of the alternative. There has never been a safety issue with current practice.
STEP 5 TEAM CONCLUSION:

□
X Continue Current Practice □ Implement Alternative Practice
STEP 6: DOCUMENT THE RESULTS: NA – narrow scope, local area decision

A. Date Submitted to the UW Health Safety Committee:
B. Summary Report to UW Health Safety Committee: (attach report if additional space needed)

C. Oversight Committee Decision:
□ Continue Current Practice □ Implement Alternative Practice
D. If Implementing Alternative, Responsible Party for Implementation:
E. Projected Implementation/Completion Date:
F. Monitoring Strategy:
STEP 7: MONITOR AND REASSESS

A. FINDINGS OF MONITORING STRATEGY

B. REASSESSMENT
□ Continue 6C Decision □ Develop Alternative Practice (Repeat Risk-Assessment Process)

Source: University of Wisconsin Hospitals and Clinics, Madison, WI. Used with permission.
35
36

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EBECRA15Sample Risk Assessment Hospital

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Chapter 1: Risk-Assessment Basics . . . . . . . . . . . . . . . . . . . . . . . . . 7

Chapter 3: Hazardous Materials and Waste . . . . . . . . . . . . . . . . . . . . . 67

Chapter 5: Fire and Life Safety . . . . . . . . . . . . . . . . . . . . . . . . . . . 103

Chapter 6: Medical Equipment . . . . . . . . . . . . . . . . . . . . . . . . . . . 131

Chapter 7: Utilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143

Chapter 8: Emergency Management . . . . . . . . . . . . . . . . . . . . . . . . 153

Chapter 9: Construction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165

Chapter 10: Intracycle Monitoring . . . . . . . . . . . . . . . . . . . . . . . . . 185

• Patient falls • Safety officers

By taking a proactive approach to assessing risks in the Acknowledgements

Contents of This Book

Chapters 2 through 8 offer information on risk assessments

Chapter 9 discusses specific risks that arise during a demoli-

Chapter 10 closes out the book with information about the

Although a risk-assessment process in health care can be Why Assess Risks?

housed. He compiles the results in a dashboard. The

When a new CEO arrives, the facilities manager

DASHBOARDING SAMPLE—STANDARD ANALYSIS WORKSHEET

The hospital designs and installs utility

Written inventory of operating

Written documentation that high-risk

Written documentation of activities and

Written documentation of activities and

Qualified individual utilizes written

Written documentation of operating

Utility system controls are labeled

Written procedures for responding to

Electricity Yes Yes Yes Yes

Natural Gas Yes Yes Yes Yes

Medical Air Yes Yes Yes Yes

Vacuum Yes Yes Yes Yes

HVAC (Heating, Ventilating, and Air

Water Yes Yes Yes Yes

Communication Systems Yes Yes Yes Yes

Information Technology Yes Yes Yes Yes

Procedures address shutting off the

Procedures address performing

Procedures address how to obtain

Hospital responds to utility system

Minimizes pathogenic biological

Appropriate pressure relationships,

109.94% 8.81% 107.42% 11.33% 100.60% 18.15% 110.18% 8.57%

DASHBOARDING SAMPLE—STANDARD ANALYSIS WORKSHEET continued

EC.02.05.01 Element of Performance Compliance Rate

DASHBOARDING SAMPLE—IN-DEPTH DATA ANALYSIS WORKSHEET

Non- Non- Non- Non- Non- Overall

OR 3 (2) 149 16 176 12 92 17 92 0 509 45 91.88%

OR 8 (2) 152 0 154 1 156 2 156 0 618 3 99.52%

Clean Core 4 (4) 227 1 228 3 232 2 234 0 921 6 99.35%

L&D Sterile Storage (1) 90 0 91 0 92 0 92 0 365 0 100.00%

Post-Op Isolation C (2) 176 0 182 1 180 0 178 0 716 1 99.86%

Laboratory C 158 0 161 0 140 0 143 0 602 0 100.00%

DASHBOARDING SAMPLE—IN-DEPTH DATA ANALYSIS WORKSHEET continued

Air-Pressure Relationships—Daily Verification of

OR 2 (2) 88.67% 11.33% OR 2 88.67% 11.33%

OR 3 (2) 91.88% 8.12% OR 3 91.88% 8.12%

OR 4 (2) 93.65% 6.35% OR 4 93.65% 6.35%

PACU (2) 91.07% 8.93% PACU 91.07% 8.93%

Clean Core 1 (4) 86.77% 13.23% Clean Core 1 86.77% 13.23%

OR 5 (2) 99.68% 0.32% Pharmacy 95.46% 4.54%

OR 6 (2) 99.68% 0.32% Central Sterile—Dirty (6) 93.02% 6.98%

OR 7 (2) 99.52% 0.48%