The Survey Coordinator’s Handbook, 17th Edition

Accreditation Monthly, February 15, 2016

Risk Reduction Strategies

Editor's Note: this is an excerpt from The Survey Coordinator’s Handbook 17th Edition.  Please click here for more information or to order.
What is the best way to prepare for patients each and every day? The best way is to create a safe, effective, and efficient system for providing patient care. It is to become knowledgeable and identify issues in an effort to minimize risks and maximize best outcomes. It is to be prepared. As a survey coordinator, you know best what your organization does and what patient population it serves. You have a distinct advantage in ensuring that the survey team understands your organization and how you operate
to maintain compliance and minimize any risk that might be identified. Demonstrating to the survey team that your organization has given thoughtful consideration to issues that may present risks to the patient and to the patient care process is an important aspect of the survey.

A basic risk assessment is a process to proactively evaluate the potential for adverse impacts associated with systems and processes, both internal and external to the organization, and related to patients, staff, visitors, and others with regard to patient care and safety or as required by law or regulation.

Conducting a basic risk assessment would likely include the following (or a variation of the following) steps:

1. Identify the issue
2. Identify arguments in support of the issue
3. Identify arguments against the issue
4. Evaluate both arguments
5. Come to a conclusion
6. Document the process
7. Monitor the conclusion to ensure that it is correct

When conducting a basic risk assessment, there are several elements of focus. These include an assessment of the valuables that need to be preserved or protected, identification of any threats that might be present or possible, identification of any potential areas of vulnerability or loss, and identification of the controls currently in place. The primary goal is to identify the probability of risk.

The Joint Commission requires organizations to conduct risk assessments. National Patient Safety Goal(NPSG) 15.01.01 requires a risk assessment for addressing suicide prevention as well as emergency management and infection control. Note that risk assessments as reviewed here are not the same as the Failure Modes and Effects Analysis (FMEA), which is a much more complex study of a process or an
The following are the required Joint Commission risk-assessment topics:
• Suicide
• Safety and security: Violence in the workplace
• Infection control (IC) program
• IC: Multidrug-resistant organisms (MDRO)
• IC: Construction and renovation projects
• Falls: Assessment and prevention program
• Fire/life safety

Additional topics to consider are hospital-specific:
• Issues based on patient population, community, etc.
• Identification of inconsistent practice
• Lack of clear decision or consensus related to practice or issue
• Methods for assessing compliance and avoiding requirements for improvement

A risk assessment can be a valuable tool when you want to ensure that your organization has reviewed and supports the position that has been taken on a specific issue. Risk assessments are also helpful when a standard requires them or when you have a unique or organization-specific approach that might not be fully documented in the literature or used frequently in other healthcare organizations. The best way to position your organization is to conduct a review of your process before the issue is raised in a survey.

This has been an excerpt from The Survey Coordinator’s Handbook 17th Edition.  Please click here for more information or to order.


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