The Importance of Performing EC Risk Assessments

Accreditation Monthly, November 6, 2005

Dear Colleague,

Does JCAHO prohibit storage of materials or supplies in sink cabinets? Do electrical outlets in our waiting or examination rooms need child-proof plug caps? Do we need to lock the doors of our clean utility rooms? How about the chemical supply compartment on our housekeeping carts? How frequently do eye wash stations need to be checked?

These and hundreds of other similar questions are often on the minds of hospital safety officers and JCAHO compliance professionals who always try to comply with applicable standards and "Do the Right Thing" to produce a safe environment for patients and staff. What are the correct answers? Where does one look for a definitive source or best practice? As we take steps to address each question, how do we defend our stance to a skeptical or even close-minded JCAHO surveyor steadfast in his or her belief that we should have done something else?

In large measure, the answers to these questions lie in Environment of Care standard EC.1.10, EP#4. This element of performance calls for the hospital to conduct "comprehensive, proactive risk assessments that evaluate the potential adverse impact of buildings, grounds, equipment, occupants, and internal physical systems on the safety and health of patients, staff, and other people coming to the hospital's facilities."

In essence, unless specifically called for in a standard or element of performance, the JCAHO leaves it up to the organization to research and decide the best way to create and sustain a safe environment. If when visiting your hospital something in the environment causes a rise in the surveyor's eyebrow (e.g., the absence of child-proof outlet caps), you'll avoid a finding if you are able to produce evidence of having performed a risk assessment and implemented the results of the assessment.

What should the assessment look like?

I recommend a simple format:

  1. Identify the issue
  2. Research and present the case for one action or another
  3. Evaluate the pros and cons of each action and make a decision
  4. Implement the chosen action, monitor, and reassess the action to ensure proper design and sustained execution
  5. Document pertinent details of steps 1-4

In addition, I recommend creating a policy and procedure to guide your risk assessment activities. The P&P should describe the actions required to initiate and conduct an initial risk assessment and the actions required to re-evaluate a risk assessment as part of the annual evaluation of the EC programs. All existing programs should be assessed initially and reviewed periodically or as deemed necessary.

A risk assessment of all new services and of all areas undergoing major renovation, alteration, or conversion should be conducted prior to occupancy and/or use. The risk assessment findings will be used to identify protective measures necessary for ensuring personnel safety and serve as a data source for ongoing Hazard Surveillance.

To determine the appropriate score for each identified risk, consider information obtained through a physical tour of the facility, regulatory compliance standards or mandates (OSHA, NFPA®, JCAHO®, DOH, etc.), review of annual incident and accident statistics, review of at least the past 12 months EC Committee minutes, Environmental Tours/Hazard Surveillance reports, interviews with department heads, best demonstrated practices and on unit interviews with a representative sampling of staff.

Scoring grid

To help create objective assessment criteria, I suggest adopting this scoring grid:









A high-risk area with possible life threatening or disabling consequences, as well as some history of associated incidents with serious injury.




A high or significant risk area with possible life threatening or disabling consequences and no history of associated incidents with serious injury.




A moderate risk of minor injury or inconvenience to patients, visitors, or staff.




A minimal risk of minor injury or inconvenience to patients, visitors, or staff.




Virtually no risk of injury or inconvenience to any one.

Of course you'll want to incorporate into your decision making process the unique requirements of state or local regulators who may hold a particular issue to a more definitive standard. Effective use of risk assessments goes a long way to maintaining a safe environment - safe for patients and staff - and safe from the JCAHO requirement for improvement findings.


John Rosing
Practice Director of Accreditation
and Regulatory Compliance
The Greeley Company

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