Annual Conference Dispatch

Seven Steps
to Risk Assessments
Conducting risk This article is based on a presentation
from the 2014 ASHE Annual

assessments and failure Conference & Exhibition

mode and effects analyses

60 INSIDE ASHE | SUMMER 2015

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isk assessments and failure mode and effects
analyses allow facility professionals to anticipate
problems and mitigate them before problems
occur. By understanding these processes, facility
managers can keep their facilities in compliance
and maintain a safe environment for patients,
staff, and visitors.
George Mills, director of the Department of Engineering at
the Joint Commission, said during a presentation at the 2014
ASHE Annual Conference that the Joint Commission uses risk
assessments when a specific standard is not available. The
process can be used for any issue that lacks a clear decision,
though it is important to document the process and determine
when to reassess the issue.
Joint Commission EC.02.01.01 EP 1 requires hospitals
to identify safety and security risks associated with the
environment of care that could affect patients, staff, and
visitors. Risk identification can be done through ongoing
monitoring of the environment, results of annual risk
assessments, and results of root cause analyses. This element
of performance seeks to ensure that hospitals have a risk
assessment process in place, Mills said.
Joint Commission EC.02.01.01 EP 3 requires hospitals to
take action to minimize or eliminate identified safety and
security risks in the physical environment. This element of
performance seeks to ensure that hospitals responded to
their risk assessment findings and corrected the identified
risk, Mills said.
Several tools exist to help facility risk assessment, Mills
said, including:
• Environmental tours
• Interim life safety measures and infection control
risk assessments
• Observing the environment while walking around
• Documentation such as inspections and tests
Risk Assessment Steps
Mills recommended a simple seven-step risk
assessment process that facility professionals can
use. “This is probably the simplest process the Joint
Commission can lay claim to,” Mills said.
1
Identify the issue: If you notice an issue that
gives you pause and there are no codes or
standards covering the topic, conduct a
risk assessment. The first step is to simply
state what issue is under consideration. For
example, Mills said, imagine you are a facility
director on tour in the ICU and you notice a box of sharps
in the bedside stand. No agency says you can’t have sharps
in the bedside stand, but it seems like a bad idea to you.
Under step one, you identify the issue as follows: Can I have
sharps in the bedside stand in the open bay ICU?
Develop arguments in
support of the issue: This step is as simple
as taking a piece of paper, drawing a
line down the middle, and writing down
arguments in support of the issue, Mills
said. In this case, talk to various parties and
think about why it would be good to have sharps in the
bedside stand. They are convenient to nurses and can be
quickly used, so it makes sense from the point of view of
doctors and nurses.
3
Develop arguments against the issue:
Next, write down the arguments against the
issue. Public perception could be negative if
patients and their families see sharps in the
bedside table. There may be the potential for
theft, and a potential for harm if children can access them
when visiting relatives.
4
Objectively evaluate both arguments:
Hash out the issue—consider both sides and
thoroughly think through the arguments.
Consider details such as the ICU open bay—it
may make sense to keep sharps in a bedside
stand since there is 24-7 visibility.
5
Reach a conclusion: After evaluating both
sides of the issue, imagine you determine
that it is proper to have sharps in the
bedside stand because of the visibility.
Document the process: Clearly record the
6
process and the decision; this is critical for
Joint Commission compliance.
7
Monitor and reassess the conclusion to
ensure it is the right conclusion:
This step involves following up to
determine whether the correct choice has
been made. In this case, Mills suggested, you
could examine the issue three months later.
Ask whether there have been any negative comments
from patients or visitors. Ask whether there have
been any injuries or thefts. Talk to doctors and nurses
to see if they still find the sharps convenient. This
follow-up step can reaffirm the decision or cause a
facility to rethink the issue.
continued on page 63
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 ...the important thing is to keep an open mind so you can
critically think about the issue at hand.
3
Mills said the example given above was a real-world
experience. A surveyor on site saw sharps in the bedside
stand and asked the facility professionals whether they
had conducted a risk assessment. The organization had
done a risk assessment and showed the documentation
to the survey. The surveyor said “good job” and
moved on, Mills said, highlighting the value of the risk
4
assessment process to health care facilities.
When conducting risk assessments, Mills stressed that
it is important not to have any preconceived notions.
Don’t hope the issue goes one way or worry about the
amount of money that something would cost to fix—the
important thing is to keep an open mind so you can
critically think about the issue at hand.
5
“Don’t put yourself in a box,” he said.
Mills also explained how to conduct a failure mode
and effects analysis (FMEA). FMEAs, like risk assessments,
take a proactive approach to preventing problems
before they happen. They look for the weak link in a
process and can also be conducted through a seven-
step process.
6
Failure Mode and Effects Analysis
1
At least every 18 months, select at least one
high-risk process: High risk processes may include
7
non-standardized processes or those with input from
many sources. They may be new processes or new
equipment.
2
Describe (diagram) the intended and actual
performance: Define the current process and specify
what makes it high risk. Define the desired outcome
or proposed changes. During this step, flow charts,
matrixes, narratives, and performance improvement
tools may be helpful, Mills said.
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Identify potential ways the process could
break down or its failure modes: Assemble
a team to help identify the high-risk process and
ask “what if” and “why” questions. Determine
potential problems, including potential breakdown
conditions and potential failure modes.
Prioritize these potential risks of breakdown
or failure: Rank the potential risk to patients,
including severity. Rank potential causes of
breakdown discussed in step three. Then
prioritize the potential risks of breakdowns or
failure modes by severity and actual risk.
Redesign the process: For each potential
failure model or breakdown, describe an action
to prevent it. Assemble the actions into a new
process, and identify the outcome measures that
will later be used to evaluate the redesigned
process.
Implement and test the redesigned process:
Under controls, implement the redesigned
process and begin the testing process to gather
input data that will be used to evaluate the new
process.
Monitor the effectiveness of the redesigned
process: Review the data collected in step
six and determine whether the high risk has
been reduced. If so, then design expanded
implementation strategies and communicate the
outcomes to leadership.
To listen to the entire session on these topics, or to
browse other available session recordings from various
ASHE conferences, visit prolibraries.com/ashe.
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