As Joint Commission surveyors conduct tracers during your survey, they are on the look-out for features in the environment that potentially create a safety risk for your clients. In particular, environmental suicide risks are frequently cited in surveys of psychiatric hospitals, psychiatric units of acute care hospitals, residential behavioral health programs and sometimes even in outpatient behavioral health settings. Examples of issues cited on surveys include use of plastic trash can liners, loopable hardware in bedrooms and bathrooms, and non-breakaway rods in closets and showers.
When these risks are identified, the surveyor typically asks if the organization has conducted a risk assessment on the issue. All too often, the organization is unable to demonstrate (and document) that they have conducted a formal risk assessment, analyzed the results and made an informed decision about how to address the identified risk. As a result, the organization is cited as non-compliant with the following standard:
EC.02.01.01 (in both the Hospital and BH manuals) "The hospital/organization manages safety and security risks."
EP 1: "The hospital/organization identifies safety and security risks associated with the environment of care."
EP 2: "The hospital/organization takes action to minimize identified safety and security risks associated with the physical environment."
So, how does one go about conducting a risk assessment on a particular safety issue that has been identified? TJC published an excellent article on this topic in the March 2013 issue of Perspectives titled "Risk Assessment Process: A Seven-Step Approach". One of the examples they used was the issue of exposed plumbing in a Behavioral Health Unit (which has been cited on several of our clients' surveys.) They provided the following example of using the 7 step model to conduct a risk assessment on this issue:
Step 1: The issue: Can we have exposed plumbing in a BH unit?
Step 2: Arguments supporting "yes"
- Maintains a standardized look for all patient rooms
- Have no history of adverse events associated with exposed plumbing
- Have clinical interventions in place to prevent patient self harm even with pipes present
- Could have designated high risk rooms that don't have exposed plumbing
- As treatment progresses, patient could move from a high risk from to a low risk room.
Step 3: Arguments supporting "no"
- Exposed plumbing presents opportunities for patient self harm.
- What if a clinical intervention fails? How do we prevent patient harm then?
Step 4: Evaluation
- Include all stakeholders: unit physicians, nursing staff, risk management, facilities, and administration representatives.
Step 5: Conclusion
- Decide whether to allow exposed pipes in BH units.
Step 6: Documentation
- Update relevant policies with information based on the decision.
- Share the decision with the Safety Committee.
Step 7: Monitoring and reassessment
- Revisit the topic in three months.
- If decision is valid, revisit annually.
This 7 step model of risk assessment is relatively straightforward and easy to use. To ensure that your risk assessment is as robust as possible, we recommend the following additional strategies:
- When evaluating the specific risk, be sure to bring data to the table. Review your incident database, client satisfaction data and complaints. Summarize the relevant data and present it to the group for their review and analysis.
- Conduct a literature review to identify current professional thinking and best practices related to the topic.
- Research the regulations. Clarify the TJC, CMS and state licensing requirements related to the issue.
- Once you have reached a decision, clearly state your "organizational position" and include a full rationale for how you decided upon this position.
- Write up the risk assessment as a formal report. You can use the 7 step model as your outline.
- Have the formal risk assessment report reviewed by the appropriate committees and attach it to their minutes. Once these bodies have reviewed the risk assessment and approved the organizational position, include this approval in the final risk assessment report itself (see example below).
Date of Review & Approval
January 5, 2013
February 10, 2013
March 15, 2013
Keep in mind that the purpose of conducting a risk assessment is threefold:
- To determine the potential risks of an action or a situation
- To evaluate the extent of those risks
- To decide whether to accept, mitigate, or avoid those risks.
In order to do this effectively, the organization should have an established process for conducting risk assessments. The 7 step model is an example of such a process. Consider using it in your organization as another one of your PI tools. To read the full article, click on March 2013 Perspectives and see page 5 "Risk Assessment Process: A Seven-Step Approach".