RISK ASSESSMENT
Your friend on survey
Kurt A. Patton
President, Patton Healthcare Consulting,
LLC
RISK ASSESSMENT
• You do it all the time in hospitals
– Fall risk assessment
– Suicide risk assessment
– Hazard vulnerability assessment EM
– Infection control risk assessment ICRA
– ILSM evaluation
– FMEA
– EC rounds, quality audits, management rounds
• All usually resulting in some change,
intervention/mitigation strategy or redesigned process
RISK ASSESSMENT
• TJC Glossary: An assessment that examines a
process in detail including sequencing of
events; actual and potential risks; and failure
or points of vulnerability; and that, through a
logical process, prioritizes areas for
improvement based on actual or potential
impact(that is criticality) of care, treatment or
services provided.
3
RISK ASSESSMENT, LESS
FRIGHTENING DEFINITION
• A formal, thoughtful evaluation of identified
potential environmental hazards that
demonstrates an assessment of the potential
risk. This may validate your immediate
impression that there really is no risk, or lead
you to the conclusion that the risk is real and
something should be done about it.
4
RISK ASSESSMENT AND A TJC
SURVEY
• Read the introduction to the LD chapter, somewhat
intense
• Read article from EC News May 2008, practical
• Risk assessment and redesign can help you to do
things better and more safely.
• New concept for today: Risk assessment leading to
no change, but validating your current process as
safe and effective can be protective on a TJC survey.
RISK ASSESSMENT EMBEDDED IN
STANDARDS
•
•
•
•
•
•
•
EC.02.06.05 (ICRA)
LD.04.04.03 (New process design)
LD.04.04.05 (Patient safety program)
NPSG.07.03.01 (MDRO)
NPSG.07.05.01 (SSI)
NPSG.07.06.01 (CAUTI)
NPSG.15.01.01 (Suicide, patients and EOC)
6
RA HAS VALUE FOR TJC TOO
• Surveyor subjectivity, surveyor opinion leading to
findings and customer complaints is a dissatisfier
• EP publication and A,B,C EP types was thought to
prevent this subjectivity.
• The principles of good process design was
thought to help eliminate this subjectivity.
• It was not enough
REAL WORLD VALUE TO RA
• Hospital complaint: The surveyor said this was dangerous,
but we disagree and there is no standard that says we have
to do it the way the surveyor suggested! We want this RFI
removed!
• TJC response: Did you do a risk assessment?
– This gives them cover. They don’t have to conclude your
process is risky, only that you failed to evaluate it as
safe.
TJC FINDINGS WHERE A RISK ASSESSMENT COULD
HAVE HELPED
• There are 3 entrances to this behavioral
health clinic.
• There are hazardous chemicals in the
laundry room on behavioral health that
could be harmful to patients.
• The pneumatic tube delivery is into the
hallway and that may lead to tampering of
medications.
VALUE OF RA
• There are 3 entrances to this behavioral health
clinic.
– Its an outpatient clinic, not IDT, no SMI, no
involuntary patients, no criminal offenders, no
incidents in many years of incident analysis,
patients use the patio for fresh air while waiting
and entries are near parking lots.
• TJC response: Did you do an RA?
VALUE OF RA
• There are hazardous chemicals in the
laundry room on behavioral health.
– The door is always locked. Patients are not
permitted in the laundry room unless
supervised by staff. Patients who are on
suicide watch, 1:1, or close observation are
not granted privileges to use the laundry
room.
• TJC response: Did you document an RA
with this mitigation strategy?
VALUE OF RA
• The pneumatic tube delivery is into the
hallway and that may lead to tampering of
medications.
– The delivery point is less than 10 feet from the
nursing station. The tube makes a racket when a
delivery arrives. Staff are in the hallway and will
see and hear the delivery.
• TJC response: Did you document a RA?
Value of a Risk Assessment, cont.
• A completed risk assessment that is presented
to the survey team can be a point of
protection during a survey or post survey
clarification.
• It means that your staff and leaders identified
this as an issue, analyzed it, document that
analysis and determined an appropriate
course of action based on the risks….
HOW DO WE IDENTIFY THE
POTENTIAL RISKS?
• Think like a stranger seeing your units for the first
time.
• Set a very low threshold to identifying potential
risk.
• Think of risk assessment as your insurance policy
to not be second guessed for decisions.
• Risk assessment is not a tedious task, think of it as
your best friend and protector.
THINK OF RA THIS WAY
15
WHO CAN IDENTIFY THESE
POTENTIAL RISKS FOR US?
• Managers or department heads in their own areas
if they can look with fresh eyes.
• Cross departmental manager visits
• Quality department staff, or the person who
everyone else thinks is too cautious or nervous.
• External mock surveyors
When do you do a Risk Assessment?
• Anytime you identify something that could
potentially cause harm or have a negative
effect on patient outcome
• If you think something may be ok, but a
hyper-vigilant surveyor may not… validate
your processes are safe
• Can be clinical or non-clinical
DON’T BE FRIGHTENED BY THE
TERM RISK ASSESSMENT
• It does not have to be as thorough as your
FMEA
• It does not have to be labor intensive
• You don’t need to schedule 6 months of
meetings
• You don’t need minutes of meetings
• You do need to document your RA though.
Sample Risk Assessment Tool is not
Complex
• This risk assessment tool is not a
– Infection Control Risk Assessment
– Hazard Vulnerability Analysis
– FMEA Failure Modes and Effects Analysis assessment
• It is a simple tool that can be used by staff
–
–
–
–
To proactively identify things that could cause harm
Assess the likelihood they will result in a negative outcome
Assess the likelihood that the harm will be significant
If necessary, implement an action plan – safeguards to prevent
20
Risk Assessment Step 1:
• Identify the potential hazard and who might be harmed
• Consider the situation from different view points using
multidisciplinary approach
–
–
–
–
What if it was night shift
What if a small child was wandering and came across this
What if the agency staff were unaware of our workaround
What if, what if what if….
Risk Assessment Step 1a: cont.
• A possible outcome is that your hospitals gets dinged by TJC
so include the potential standard violation and the risk
level associated with that standard issue:
–
–
–
–
Situational Decision Rule (2)
Direct Impact (3)
Indirect Impact
Scoring Category (A or C)
• Can include:
–
–
–
–
Data from incident reports
Data from infection control
Sentinel event alerts
Literature search on best practice
Risk Assessment Step 2:
• Describe the safeguards already in place to prevent the
potential harm
• This can include:
–
–
–
–
–
–
–
–
Structure – process – outcome
What structures prevent harm?
Possible training or staff education done to prevent harm?
What processes or policies prevent harm from happening?
Visual observation of the area/situation ongoing
Data from incident reports
Data from infection control
Literature search to support your process
Risk Assessment Step 3:
• Assess the level of risk posed by the potential hazard and
decide if the measures currently in place are adequate to
prevent harm or should more be done…
• Assess the risk on two scales:
– Likelihood – assess the likelihood of harm occurring from the potential hazard
– Severity – assess the possible severity of the outcome if the negative event
occurred.
• Place an “X” in the box corresponding with your score
SLIGHTLY MORE COMPLEX USING 3
AXIS OR FACTORS
• Likelihood/probability
• Severity
• Preparation or mitigation strategy
– Always use this 3 axis technique for suicide
hazards
• Can add to complexity with 4 outcomes,
using extreme above high
Risk Assessment Step 3: cont
• If the box checked is “low”, then submit to your
safety manger, obtain their signature under
“reviewed by” and date. Keep copy in your
department, send copy to hospital quality.
– You are done for now
– Consider redoing the assessment at some point
because conditions change and acceptance thresholds
change
• If the box checked in step 3 is medium or high
risk, DO SOMETHING, complete an action plan
Risk Assessment Step 4:
The Action Plan
• Implement an action plan when you decide
we have to do something.
• The goal is to reduce the chance of risk by
implementing safeguards
• What action is needed, what time frame,
communication plan
• Track completion, record and save
• Reassess after the intervention
The Action Plan
MITIGATION STRATEGY
• Not an action plan, but a strategy that is
already in place that protects our patients
from harm.
• Always identify the mitigation strategy for
suicide hazards.
– Staffing, clinical screening, precautions,
reassignment of high risk patients to another
room.
SPECIALIZED RISK ASSESSMENTS
• Suicide hazards per NSPG.15.01.01
– EP 1: “Conduct a risk assessment that identifies
specific patient characteristics and environmental
features that may increase or decrease the risk for
suicide.
• EC.02.01.01
– EP 1: “The hospital identifies safety and security
risks associated with the environment”.
• Eye wash necessity is one example of this type or RA
31
IDENTIFYING SUICIDE HAZARDS
• Look for and identify environmental features that
could allow an unsupervised patient to injure
themselves or others.
• Use a very low threshold for potential risk
• Use potential risks such as identified by NAPHS
• https://www.naphs.org/Design%20Guide%205_1_FI
NAL_051412.pdf
• VA and ECRI also have tools that can help you
identify potential suicide hazards.
32
IDENTIFYING SUICIDE HAZARDS
• Don’t forget to include those parts of the ED
which serve behavioral health patients,
including the bathrooms they will use.
33
WHAT DO WE DO AFTER IDENTIFYING ALL THE
POTENTIAL HAZARDS?
• 1. Spend several million dollars to fix them all this
immediately.
• 2. Develop a multiyear plan to get them all fixed.
• 3. Evaluate the degree of risk for each potential
hazard and fix the most significant problems and
develop a thoughtful mitigation strategy for those
that cannot be immediately corrected.
34
WHAT IS A MITIGATION STRATEGY?
• Create some safer rooms, clinically screen
patients and:
– Prioritize placement
– Place on 1:1 supervision
– Allow entry to some areas only when supervised
35
DOCUMENTING THE RISK
ASSESSMENT
• Can use the PHC tool and multiply:
– Probability of use 1-3
– Outcome if used 1-3
– Detectability 1-3
• Worst possible outcome is 9, for immediate correction
• Detectability: The most problematic because supervision may
be inadequate.
– Less easy to see inside the patients room, less still to see inside the
patients bathroom. Make the less detectable areas safer first.
36
37
EYE WASH RISK ASSESSMENTS
• Lots of scoring for failure to have an eyewash
the past 2 years.
• Plumbed eyewash requires weekly testing and
annual inspection.
• OSHA would mandate if you use corrosive
chemicals. No choice or decision
• Many chemicals used that are irritating to the
eye.
38
EYE WASH RISK ASSESSMENTS
• Non corrosive, but irritating chemicals can be
evaluated using the risk assessment tool.
–
–
–
–
–
Evaluate the relative risk, for example pouring from one container to another, vs using a wipe that contains
the chemical. High risk gets 3 points, low risk gets 1 point.
Evaluate the relative risk based on hospital experience, your incident reporting system and the professional
literature. Assign 3 points if you have reports and the literature reports this being a problem, assign 2
points if you have never experienced a problem and there is only one or very few reports in the literature.
Assign 1 point if you have never experienced a problem and there are no reports in the literature.
Evaluate the inherent staff mitigating factors such as staff always wearing PPE and eye protection. Assign 1
point if PPE and eye protection is available and staff routinely where it. Assign 2 points if eye protection is
not available or not used.
Evaluate staff preparation, or ability of staff to assist each other. If there is a splash, can staff guide, aid
their coworker to a plumbed eyewash? Assign 1 point if there are always staff to assist, and 2 points if the
worker is alone in this area.
Evaluate how long it would take to get to a plumbed eyewash if needed. Assign 3 points if longer than 30
seconds, 1 point if less than 10 seconds, 2 points between 10 and 30 seconds.
39
MOST IMPORTANT TAKE AWAY
• Risk assessment is not to be feared
• Risk assessment is your insurance policy
against being second guessed for failure to
consider an issue.
• Learn to do it early and often
• Make sure multiple leaders have copies and
awareness of the risk assessment.
40
Questions?
Kurt@PattonHC.com