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Greeley Reflections

Accreditation Connection, January 18, 2010

Risk assessments for unclear standards

Part 1 of 4

When the Joint Commission released its "Power Pack" on medication storage it suggested at least two risk assessments (access to respiratory care medications and storage of electrolytes). Risk assessments are also commonly accepted as an effective way to deal with surveyor preference for blanket warmer temperatures, suicide opportunities in behavioral healthcare units, use of "fanny packs" to transport medications, and scores of other issues. It's time, therefore, to review how to perform and document these risk assessments.

A risk assessment should be performed:

• When it's specifically required by the standard, including risk assessments and risk reduction strategies related to the environment of care, emergency management, and infection and leadership.
• When there's a frequently cited or problematic issue for which there are no specific regulatory requirements.
• When your approach to compliance is unusual, making it likely that surveyors will question why you chose your approach to the item of focus.

Note: LD.04.04.05 discusses an expectation for a very detailed risk assessment once every 18 months for a patient care process. This is widely known as the failure mode and effects analysis (FMEA) standard. Please don't confuse what we're suggesting with an FMEA. We're discussing a one- or two-page document that supports your position related to a frequently cited issue; something that takes surveyor preference out of the compliance equation.

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