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Safety/Security - Risk Assessment Frequency

How often are safety and security risk assessments required to be performed after the initial evaluation is completed?

Any examples are for illustrative purposes only.

Environment of care standards do not require safety and security risk assessments to be done at any particular frequency, but reassessment is to be done when significant changes to the environment of care occur. It is a good practice to schedule assessments for high risk issues on a regular frequency in order to incorporate new tools or knowledge that may have become available.  

EC.02.01.01 EP 1 requires organizations to implement a process to identify safety and security risks.  Additionally, the risks should come from internal sources such as ongoing monitoring of the environment, results from root cause analyses and results of proactive risk assessments (see the EP for more information).  Furthermore, EP 3 states the organization takes action to minimize or eliminate identified safety and security risks in the physical environment; meaning it's not enough to just identify, there needs to be follow up action. 

An annual evaluation of safety and security management plans is a requirement, so annual risk assessments are helpful tools to identify goals and objectives, and to recognize changes that have occurred in the environment.  Compliance with all elements of performance within the EC.02.01.01 standard for safety and security issues lend themselves to the assessment process because effective management depends upon analysis of the organization's particular circumstances. If an organizational policy establishes frequencies of assessment, then the established schedule is to be followed. 

Reference EC.02.01.01 EP 1, EP 3
Manual: Hospital and Hospital Clinics
Chapter: Environment of Care EC
Last reviewed by Standards Interpretation: May 31, 2023 Represents the most recent date that the FAQ was reviewed (e.g. annual review).
First published date: April 11, 2016 This Standards FAQ was first published on this date.
This page was last updated on May 31, 2023 with update notes of: Review only, FAQ is current Types of changes and an explanation of change type: Editorial changes only: Format changes only. No changes to content. | Review only, FAQ is current: Periodic review completed, no changes to content. | Reflects new or updated requirements: Changes represent new or revised requirements.
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