How and when are risk assessments required to be performed?

Any examples are for illustrative purposes only.

The Joint Commission is not prescriptive as to how risk assessments are 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 will mitigate 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 and modify to their specific needs.

Examples of other tools are, but not limited to:

• Root Cause Analysis
• Failure Mode and Effect Analysis
• Strength Weakness Opportunities and Threat Analysis (SWOT)
• Gap Analysis
• Delphi Technique
• Outputs to Identify Risks
• Probability and Impact Matrix

Best practice approach is to report the results and recommended actions to a multi-disciplinary team such as the Safety, Environment of Care, or Infection Control Committee, to facilitate implementation of the actions required to minimize or eliminate risks in the physical environment.

Reference: EC.02.01.01