Environment of Care
®
Risk Assessment
SECOND EDITION
Senior Editor: Kathleen DeMase
Project Manager: Lisa King
Associate Director, Publications: Helen M. Fry, MA
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Joint Commission/JCR Reviewers for the second edition:
Tracy Collander, LCSW; Jeff Conway, MPH; John Fishbesk; Michael Kulczycki, MBA, CAE; Margherita Labson, RN,
MS, CPHQ, CCM; George Mills, MBA, FASHE, CEM, CHFM, CHSP; Diana Murray; Stacy Olea, MT (ASCP),
FACHE; Katherine Tolomeo, CHEM, CHSP; Gina Zimmerman
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CONTENTS
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
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 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
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:
5
Environment of Care® Risk Assessment | Second Edition
• Safety
• Hazardous materials and waste
• Security
• Fire and life safety
• Medical equipment
• Utilities
• Emergency management
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.
7
Environment of Care® Risk Assessment | Second Edition
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
9
Environment of Care® Risk Assessment | Second Edition
FIGURE 1-1
In-Depth
Data Non- Non- Non- Non- Overall
EP Category Deficiency red Description Compliant compliant Compliant compliant Compliant compliant Compliant compliant Compliance
Sanitation No No No Yes
Elevator No
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%
10
Chapter 1 | Risk-Assessment Basics
FIGURE 1-1
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%
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%
Environment of Care® Risk Assessment | Second Edition
FIGURE 1-2
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
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
12
Chapter 1 | Risk-Assessment Basics
FIGURE 1-2
13
Environment of Care® Risk Assessment | Second Edition
FIGURE 1-2
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
Chapter 1 | Risk-Assessment Basics
FIGURE 1-3
Bolded standards are examples of noncompliance for an organization with a goal of 95% or greater.
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.02.01.35
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
15
Environment of Care® Risk Assessment | Second Edition
FIGURE 1-3
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
Chapter 1 | Risk-Assessment Basics
17
Environment of Care® Risk Assessment | Second Edition
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
Chapter 1 | Risk-Assessment Basics
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
Environment of Care® Risk Assessment | Second Edition
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
20
Chapter 1 | Risk-Assessment Basics
FIGURE 1-4
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
Environment of Care® Risk Assessment | Second Edition
FIGURE 1-4
Requirement Frequency Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Comments
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/
Occupancy 2 12 Months
Business Monthly/
Occupancy 3 12 Months
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
Chapter 1 | Risk-Assessment Basics
FIGURE 1-4
Requirement Frequency Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Comments
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/
Occupancy 1 12 Months
Business Monthly/
Occupancy 2 12 Months
Business Monthly/
Occupancy 3 12 Months
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
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Environment of Care® Risk Assessment | Second Edition
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).
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Chapter 1 | Risk-Assessment Basics
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:
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
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Environment of Care® Risk Assessment | Second Edition
FIGURE 1-6
Arguments
Communication plan:
26
Chapter 1 | Risk-Assessment Basics
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
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Environment of Care® Risk Assessment | Second Edition
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.
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Chapter 1 | Risk-Assessment Basics
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.
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Environment of Care® Risk Assessment | Second Edition
FIGURE 1-7
DMAIC METHODOLOGY
Using the DMAIC methodology will help improve an existing process for an organization.
FIGURE 1-8
DMADV METHODOLOGY
To create new process designs, organizations may use the DMADV methodology.
30
Chapter 1 | Risk-Assessment Basics
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
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Environment of Care® Risk Assessment | Second Edition
■ 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
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Chapter 1 | Risk-Assessment Basics
■■ 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.
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Environment of Care® Risk Assessment | Second Edition
FIGURE 1-9
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
□
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
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.
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Chapter 1 | Risk-Assessment Basics
FIGURE 1-9
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.
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:
Source: University of Wisconsin Hospitals and Clinics, Madison, WI. Used with permission.
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Environment of Care® Risk Assessment | Second Edition
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