Risk Assessments - Definition and Requirement For Conducting

When would The Joint Commission expect a risk assessment be performed ?

A risk assessment is defined as “An assessment that examines a process in detail including sequencing of events, actual and potential risks, and failure or points of vulnerability and that prioritizes, through a logical process, areas for improvement based on the actual or potential impact (that is, criticality) of care, treatment, or services provided.”

Such an assessment is only required when explicitly noted in the language of the element of performance. Here are two examples from the Hospital Manual:
EC.02.06.01 EP 2 states "When planning for demolition, construction, or renovation, the hospital conducts a preconstruction risk assessment for air quality requirements, infection control, utility requirements, noise, vibration, and other hazards that affect care, treatment, and services."

LD.03.09.01 EP 7 states "At least every 18 months, the hospital selects one high-risk process and conducts a proactive risk assessment."

 Additionally, organizations are to assess for risk whenever there is a process vulnerability or high risk procedure that could result in a poor outcome. For example, environmental ligature points, infection prevention/control, vesicant infusions, etc. While failing to complete a risk assessment may not result in a recommendation for improvement, conducting a risk assessment cannot be used to supersede requirements listed in the accreditation requirements or what is required by law and regulation.

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.   Other examples may include a root cause analysis, failure mode and effect analysis, plan/do/check/act process, etc., or combinations and variations of such tools.
Last updated on February 06, 2019
Manual: Hospital and Hospital Clinics
Chapter: Leadership LD

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