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February 13, 2013

Tips for compliance: A seven-step approach to risk assessment

The Joint Commission requires organizations to regularly assess and respond to risks in the health care environment. This should include a defined process for examining risks and their potential consequences, determining mitigating factors, and whether safeguards are needed to prevent or lessen identified risks. The risk assessment process should be appropriate for the organization’s size, scope and patient population. Following is a seven-step approach that can help:

Step 1: Identify the issue. Avoid combining several issues in a risk assessment; try to frame the issue as a yes/no question. For example, “Can we bring cardboard shipping boxes into central supply?”
Step 2: Develop arguments that support the proposed process or issue. Create a list of advantages or reasons that support the issue. Things to consider may include the impact on patient care delivery, staff, the work environment, visitors, public safety, and finances.
Step 3: Develop arguments that oppose the proposed process or issue. These can be perceived concerns or situations that may pose a potential risk or that may impact a situation negatively. Consider asking questions similar to those in Step 2.
Step 4: Evaluate both arguments. The evaluation should be impartial and involve all the stakeholders affected by the decision.
Step 5: Reach a conclusion. Decide to accept the risk or to take steps to mitigate or avoid the risk. After making a decision, it’s a good idea to submit a report of the risk assessment to the safety or performance improvement committee to ensure organizational consensus about the issue’s resolution.
Step 6: Document the process. The report to the safety or performance improvement committee or minutes of the multidisciplinary committee meeting can serve as documentation. Remember to update any relevant policies.
Step 7: Monitor and reassess the conclusion. Establish a monitoring strategy, including a specific date or time frame in which to reassess the issue and the resulting conclusion. If the reassessment determines that a different decision should have been made, submit the issue to the multidisciplinary committee for review. If the reevaluation confirms the conclusion, document the confirmation, and decide whether further monitoring is necessary.

For more information, see “Risk Assessment Process: A Seven Step Approach,” in the March 2013 issue of The Joint Commission Perspectives. (Contact: George Mills,



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