RISK ASSESSMENT Your friend on survey July 2012 Kurt A. Patton.

RISK ASSESSMENTYour friend on survey

July 2012

Kurt A. Patton

RISK ASSESSMENT• You do it all the time in hospitals– Fall risk assessment– Suicide risk assessment– Hazard vulnerability assessment– Infection control risk assessment– FMEA– Readiness rounds, quality audits, management rounds

• All usually resulting in some change, intervention/mitigation strategy or redesigned process

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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.

RISK ASSESSMENT AND A TJC SURVEY

• Read the introduction to the LD chapter• Read article from EC News May 2008• 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.

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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)

RA HAS VALUE FOR TJC TOO• Surveyor subjectivity, surveyor opinion leading to

findings and customer complaints exasperates TJC leadership.

• 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 DID NOT WORK!

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.

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 20 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 clarification after.

• 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.

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THINK OF RA THIS WAY

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. • We have probably already done it on our mocks,

where you think we are too cautious/nervous

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.

PHC 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

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….

• Record the potential hazard and population impacted in box 1

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

Simple Risk Assessment Two Axes, Five Point Scale, Three Outcomes

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

manger, obtain their signature under “reviewed by” and date. Keep copy in department, send copy to Accreditation. – 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.

Questions?

[email protected]