Executive Summary Joint Commission Accreditation Audit

Topics: Risk management, Risk assessment, Assessment Pages: 8 (1678 words) Published: April 14, 2011
|SECTION: |EFFECTIVE DATE: October 1, 2006 | |SUBJECT: |PAGE 1 of 8 | |Proactive Risk Assessment Policy | |

This policy applies to all direct and indirect patient care processes, departments, and facilities of ABC Medical Center (ABC).

To establish a comprehensive, proactive risk assessment process to evaluate the potential adverse impact of direct and indirect patient care processes, buildings, grounds, equipment, occupants, and internal physical systems on the safety and health of patients, staff, and other people coming to ABC. This proactive risk assessment process is used to identify, rate, and prioritize risks and or hazards. Based on this risk assessment, policies, procedures, and controls may be put into place to manage the risks as appropriate to the organization, with the intent of reducing them to the lowest possible level.

ABC conducts proactive risk assessments to identify and evaluate the potential of adverse impacts of direct and indirect patient care processes, buildings, grounds, equipment, occupants, and internal physical systems on the safety and health of patients, staff, and other visitors. Risk assessments are performed on identified hazards and proposed changes to new or existing processes. Examples of proposed changes include automated or manual work processes and equipment or other technology.

The goal of performing risk assessments is to reduce the likelihood of or mitigate the impact of incidents or other negative experiences that have the potential to result in injury, accident, or other loss to patients, visitors, staff, or assets.

It is important to understand that no process, activity, or system can ever be made completely risk free. Some level of risk is always present. The concept of risk assessment involves examination of the risks and making a determination as to what level of risk is acceptable to the organization. With limited resources, the object of risk assessment is to manage the risks in a prioritized fashion.

Ultimately, ABC’s leadership is responsible to determine the acceptable level of risk. If the level of risk is determined to be unacceptable, the risk must be removed, controlled, or reduced to an acceptable level for the process or activity to continue.

Results of the risk assessment process and other potential safety issues are reported and discussed in the Patient Safety Committee (Patient Safety) meetings. In the Patient Safety process, recommendations on management of the issue at hand are reached based on the committee’s evaluation of the situation and the pertinent data. This information may be used to create or revise policies, procedures, and practices, as well as develop orientation and education programs and performance monitors.


1. The first step of the risk assessment process involves identifying potential risks to be the subject or target of the assessment process. Risks may be discovered as a result of incident reports, near misses, and environmental tours which are used to uncover environmental deficiencies, hazards, and unsafe practices. Potential hazards that are identified and do not involve simple corrections are candidates for risk assessment.

Additional sources of potential risk identification may include: • Issues reported to or identified by the Patient Safety Officer • Observations by any staff member
• Published reports in the healthcare literature
• New regulatory issues
• JC Sentinel events alerts
• Product recalls
• Inspections from outside agencies, insurance carriers, consultants...
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