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.