Risk Assessments - How and When

How/when are risk assessments required to be performed?

The Joint Commission is not prescriptive in how risk assessments are to be performed. The Joint Commission allows organizations to develop assessment methods that best suit their circumstances and preferences. Organizations may use assessment tools that they consider appropriate to achieve an outcome that mitigates or eliminates the risk. The introductory section of the Leadership (LD) chapter provides an example of a pro-active risk assessment model that an organization may use.  However, this specific approach is not mandated as there are other risk assessment tools available that may better meet the needs of the organization.   Examples are root cause analysis, failure mode and effect analysis, plan/do/check/act process, etc.; or combinations and variations. Risk assessment results should be reported to the multi-disciplinary team responsible for the Environment of Care Committee, and the Infection Control Committee if they do not share representation. An organizational policy/practice should be generated, appropriate staff trained/notified, and some method to assess effectiveness implemented. The survey process will review the risk assessment and associated policy/practice for effectiveness, and the tracer process will validate proper implementation. Some examples may be found in the Leading Practices area of the organization's Joint Commission intranet website. [EC.02.01.01]
Last updated on June 12, 2018
Manual: Ambulatory
Chapter: Environment of Care EC

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