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One way to conduct the annual risk assessment for IC.2.10

Accreditation Connection, May 8, 2006

Infection risks vary by hospital due to factors such as patient populations, surrounding communities, services and programs offered, etc. In addition, infection risks can change with time, which is part of the rationale to conduct the assessments annually, according to the JCAHO's
standard, IC.2.10.

Infection control practitioners must consider all of these differences among hospitals when designing risk-analysis programs and treatment and care services. One way to do this is through a simple spreadsheet, says Joan Brake, director of performance improvement for Hospital Partners of America in Charlotte, NC. The company consults with medical centers that create risk-analysis programs and also develops and operates hospitals in partnership with physicians nationwide.

Brake designed a spreadsheet with accompanying directions that hospitals can use to develop a risk analysis. She reiterates the JCAHO's view that each hospital has unique characteristics that it must incorporate into the analysis.

"Edit [the spreadsheet] for your area of the city and your facility and what you are seeing," Brake says.

Brake's sample spreadsheet lists organisms, diseases, and other issues. Hospital staff rate each of them by likelihood of occurrence, potential risk for death or injury, and the hospital's ability to respond to each issue.

For example, some hospitals may be in flood zones, which present a specific type of infectious risk. Others might have higher-than-average rates of tuberculosis in the community or resistant organisms (e.g., MRSA).

The IC program in the hospital should reflect what the facility has encountered, Brake says.

Adapted from an article that appears in the May 2006 issue of Briefings on Infection Control.

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