May 25 2018

NFPA 99 Risk Assessment – PLEASE READ THIS

Category: BlogBKeyes @ 12:00 am
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Q: I need to do the NFPA 99 risk assessment of my hospital. I was told by one of my consultants that I have do this risk assessment from a room-by-room perspective, and he provided me a form from ASHE that lists this assessment by room-by-room. Is this true…? Do I have to do this assessment for each room?

A: No… that’s not correct. Yes, ASHE does have a form that does imply a room-by-room assessment is needed for the Chapter 4 risk assessment, but that’s not required by Chapter 4. What is required is an assessment of building systems based on a defined risk assessment procedure. Chapter 4 does not define the risk assessment procedure that you should use, but the Annex section does identify three risk assessments that they suggest, and the ASHE room-by-room assessment form is not included in these three suggestions. To be sure, you may use the ASHE form if you wish, but then you can use any risk assessment form that you want.

The core of the risk assessment is to determine what level or category the following building systems falls under, in the event of a total catastrophic failure of that system:

  • Gas & Vacuum Systems
  • Electrical Systems
  • HVAC Systems
  • Electrical Equipment
  • Gas Equipment

There are 4 levels or categories:

  • Category 1:    Systems in which failure is likely to cause major injury or death of patients or staff
  • Category 2:    Systems in which failure is likely to cause minor injury to patients or staff
  • Category 3:    Systems in which failure is not likely to cause injury to patients or staff
  • Category 4:    Systems in which failure would have no impact on patient care or staff

The process in the assessment is to determine the level of risk to the patient or staff if there is a catastrophic failure of that particular system. Another way of saying this is “Worst case scenario”.

As an example, let’s take the hospital’s electrical system: The risk assessment must assume a catastrophic failure of the entire system. The normal power system fails, and then the emergency power system from the generators fail. In other words, you have no power whatsoever in the building. Now, what is the level of risk to your patients? It will probably be Category 1, right?

You then do that type of catastrophic failure risk assessment for each of the above listed systems. If you want, you can break this down into different assessments of systems that are the same type. Such as HVAC systems: If the HVAC system fails in patient care areas, then that would be a certain high-level of risk to the patients. But if the HVAC system fails in the Administration wing, it would not be a risk to your patients, and it would be a low risk to your staff.

For hospitals, the expectation would be all of the above systems would be assessed as a Category 1 or Category 2. But for a medical building that only has physician offices and administrative support areas, the expectation is the above systems would be assessed as a Category 3 or Category 4. All healthcare facilities must be assessed for the risk level to patients and/or staff.

You have to document your assessment using a defined process. You can down-load a simple one-page risk assessment from my website and see if that meets your expectations.

The ironic thing is, the NFPA 99-2012 Technical Committee on Chapter 4 did not intend for this risk assessment to be conducted on existing systems. I talked with two members of that committee and they said the committee believed it was obvious the way it is written that this risk assessment is only required for new construction, since most (not all) of NFPA 99 is for new construction.

But CMS did not get that message and they require all of their state agencies and accreditation organizations to evaluate the risk assessment during all surveys. In other words; They fully expect all CMS certified healthcare organizations to have the Chapter 4 risk assessments completed by now.

In my opinion, this risk assessment does not require a lot of time to conduct. As I said, CMS expects all hospitals to have Category 1 or Category 2 systems. This is something you and your staff can do.

Just last week I received a call from a friend of mine who is a facility manager in the Midwest. He returned from a regional ASHE meeting where one of his fellow facility managers was recently surveyed by a leading accreditation organization (AO). The surveyor for the AO cited them for not doing their NFPA 99 risk assessment in accordance with the ASHE form, and do a room-by-room assessment. Please understand that this surveyor was incorrect to make that citation.

There is no NFPA requirement, no CMS requirement, and no AO requirement for healthcare organizations to do a room-by-room assessment to be in compliance with Chapter 4 of NFPA 99-2012. As mentioned above, you can use whatever risk assessment format you wish. The only requirement is the risk assessment must be documented and the surveyors will expect it to be reasonable (meaning all systems in a hospital are Category 1 or Category 2 systems).

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Apr 20 2018

Eye-Wash Risk Assessment

Category: BlogBKeyes @ 12:00 am
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Q: Your articles on eye-wash station refers to the need to conduct a risk assessment. Where can I find such a document?

A: There is no set form to use for risk assessments. You can just get a group of stakeholders together and discuss the issue and the proposed solution and then write down what you discussed.

If you want a form that is based on the seven (7) steps recommended by The Joint Commission, go to my website, click on “Tools” and download the risk assessment form.

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Nov 21 2013

Risk Assessment

Category: BlogBKeyes @ 6:00 am
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images[11]A surveyor recently cited an organization for having potential suicide hanging points in a behavioral health unit, in the form of door hinges and other hardware issues in the patient sleeping rooms. While I do not believe that anyone is questioning the reality of the potential suicide hanging points that door hardware may offer, a finding on this issue is not always warranted.

You can’t have a hospital without a certain amount of risk to the patient’s safety. It’s the nature of the beast. It has been said that the process of accreditation is the ability to reduce risk, but not necessarily to eliminate risk. In Joint Commission’s standard EC.02.01.01, EP 1, an organization has the responsibility to identify safety issues in the environment. The note after the EP says: “Risks are identified from internal sources such as ongoing monitoring of the environment, results of root cause analysis, results of annual proactive risk assessments of high-risk procedures, and from credible external sources such as Sentinel Event Alerts.”

This note states that risk assessments are “ongoing” and conducted at least annually. Therefore, in the case mentioned above about the door hardware being a potential suicide hanging point, before the surveyor decides to enter a finding in the survey report he/she should ask the organization if they have a Risk Assessment on that particular safety risk. If you do have a documented risk assessment, provide it for the surveyor to review. The surveyor will determine if the mitigation factors identified in your risk assessment are acceptable. This is one of those areas where the surveyor gets to make a judgment, and determines if your risk assessment mitigates the risk to the patient.

If the surveyor determines that your risk assessment does in fact mitigate the risk to the patient (remember: this is their judgment call) then no finding is scored in the survey report. However, if your organization does not have a risk assessment on that issue, or if your risk assessment does not mitigate the risk to the patient (in the surveyor’s opinion), then the surveyor will likely enter a finding under EC.02.01.01, EP 1 or EC.02.06.01, EP 1 for an unsafe environment.

Once your organization has conducted a risk assessment, it is not a “one and done” issue; meaning you need to review the safety risks to the patients periodically. The phrase “ongoing” in the note for EC.02.01.01, EP 1 means you need to do the risk assessment over and over on the same issue, because something in the physical environment may change and the factors that mitigated the risk to the patient may not be present anymore.

How often do you need to do a risk assessment? The note for EC.02.01.01, EP 1 says annually, but a surveyor may expect you to do one more often depending on the severity of the risk to the patient and the mitigating factors.

There is no specific form or template a risk assessment must be documented on. As long as the risk assessment is documented and dated, then it qualifies. Risk assessments can be in the form of a written narrative report of a special task force formed to review the risk; or they may be in the form of a template with specific discussion points. It doesn’t matter what format your organization chooses to use – just that you do assess the risk of a safety issue.[NOTE: To download a free copy of a Risk Assessment template, go to “Tools” and click on “Risk Assessment”.]

It is considered “best practice” that the risk assessment is conducted with a group of stakeholders, such as:

  • Manager of the unit
  • Safety officer
  • Risk manager
  • Facility manager
  • Security manager
  • Administrative representative
  • Environmental services manager
  • Infection control practitioner

The purpose of the multiple individuals is to get a rounded diversified opinion concerning the risk and the mitigation factors. While it is not a requirement, I would advise you to send the completed risk assessment to your Safety Committee for their review and approval, and get the results of the risk assessment entered into their minutes.

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