Compliance News: Risk Assessments: Proactive Process for Managing EOC Safety Risks

By Dean Samet, CHSP

Performing a risk assessment is an accepted approach to identifying and minimizing safety hazards associated with the health care physical environment and services. 

Per The Joint Commission’s 2011 Hospital Accreditation Standards manual, standard EC.01.01.01: The hospital plans activities to minimize risks in the environment of care.                                                                                                                            

The Rationale for EC.01.01.01 provides the background and further explanatory information: “Risks are inherent in the environment because of the types of care provided and the equipment and materials that are necessary to provide that care. The best way to manage these risks is through a systematic approach that involves the proactive evaluation of the harm that could occur. By identifying one or more individuals to coordinate and manage risk assessment and reduction activities—and to intervene when conditions immediately threaten life and health—organizations can be more confident that they have minimized the potential for harm.

“Risks in the environment include safety and security for people, equipment, and other material; the handling of hazardous materials and waste; the potential for fire; the use of medical equipment; and utility systems. High-level written management plans help the hospital manage risks. These plans are not the same as operational plans, but they do provide a framework for managing the environment of care. These plans should also address the scope and objectives of risk assessment and management, describe the responsibilities of individuals or groups, and give time frames for specific activities identified in the plan.”  See also:

EC.02.01.01: The hospital manages safety and security risks.                       

EC.02.02.01: The hospital manages risks related to hazardous/materials and waste.

EC.02.03.01: The hospital manages fire risks.        

EC.02.04.01: The hospital manages medical equipment risks.                                                                                      

EC.02.05.01: The hospital manages risks associated with its utility systems.

The Joint Commission has certain expectations regarding risk assessments if risks are identified during a survey. The surveyor may ask about:

• What sources of information are the organizations reviewing to keep abreast of risks?

• What internal data does it use to identify risks?

• How often does it assess risk?

• Who has input into the process?

EC.01.01.01 is the standard that the surveyors often use when there are safety-related matters not covered by the other EC standards. Therefore, it is imperative to be proactive while addressing these safety matters.   

It is further recommended to: avoid combining issues; create a list of questions for both advantages and disadvantages regarding patient care delivery, staff, visitors/volunteers, work environment, public safety, financial considerations, building and grounds, equipment, and internal physical systems, etc.; conduct an impartial comparison of advantages and disadvantages; submit conclusion to safety, risk, or environment of care committee; document the process; incorporate a monitoring strategy within the risk assessment document including dates for reassessing the conclusions; perform reassessments and procedure if necessary.

Be aware that the surveyor(s) will be looking for a proactive approach as opposed to a reactive approach.

Consider using the Joint Commission “Seven-Step Risk Assessments” process which was delineated in their July 2006 Joint Commission Perspectives on Patient Safety™ as follows:

1) Identify the issue(s).

2) Develop arguments in support of an issue.

3) Develop arguments against that issue.

4) Objectively evaluate both arguments.

5) Reach a conclusion.

6) Document the process.

7) Monitor and reassess the conclusion to ensure that it is the best decision.