Greeley Reflections

Accreditation Connection, January 25, 2010

Risk assessments for unclear standards

Part 2 of 4

We've posted a sample risk assessment on the open blog for the Association of Healthcare Accreditation Professionals. Although this sample is a general guide for documenting risk assessments, it also happens to address the blanket warmer issue. This sample document can be found here. We recommend you stop, download the blanket warmer risk assessment, and then continue.

Ready? Okay, let’s look at the sample.

Section 1: State the issue, clearly and simply. In the blanket warmer example we stated the issue as a series of questions.

Section 2: Take a look at federal and state law and Joint Commission standards related to the issue. Specifically reference applicable standards so that anyone who questions your decision, including surveyors, can see for themselves what the regulations really say.

Section 3: Summarize relevant literature. Include references.

Section 4: Summarize relevant information from internal safety and quality monitoring.

Section 5: Take a look at the operational impact of the various options. What would the cost and path to implementing a change be?

Section 6: Take a stance. Clearly articulate the organization's final position about the issue.

Section 7: Indicate when the issue was approved and when.

That's it, you’re done. It’s only about two pages.

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