Risk Assessments

1. Risk Assessments Environment of Care Emergency Management Life Safety

2. Disclosure Slide • “Courtemanche & Associates Healthcare Synergists is an Approved Provider of continuing nursing education by the North Carolina Nurses Association, an accredited approver by the American Nurses Credentialing Center’s Commission on Accreditation.” • Continuing Education Contact Hours will be awarded upon full attendance of the program and receipt of the participant course evaluations. • There are no influencing financial relationships or commercial support relating to this activity. • Participation in an accredited activity does not imply endorsement by the provider or NCNA of any commercial products displayed in conjunction with this activity. • Courtemanche & Associates does not discuss any products for use for a purpose other than that for which they were approved by the Food and Drug Association. www.courtemanche-assocs.com

3. Improve Patient and Staff Safety Improve Efficiency Identify Training Issues Evaluate when answers unclear Justify a Need Why Perform?

4. Safety Hazardous materials and Waste Security Hazard Vulnerability Analysis (HVA) Statement of Conditions and ILSM Medical Equipment Utility Proactive Infection Control (PICRA) TJC Risk Assessments

5. Risk Assessment Cycle

6. No particular form required by TJC Spreadsheets PRO/CON listing Rating System Organizations will be held to the documentation requirements that are in their own policies. Document

7. Data can be used as part of the Risk Assessment: PI Data Staff, Patient and Family Feedback Environmental Tracers Root Cause Analysis JC publications Internal and External Data

8. Identify Issues Develop arguments that support a process Develop arguments that disagree with a process Evaluate both arguments Reach a Conclusion Document the process Monitor and Reassess Simplifying ProActive Risk Assessment

9. Create a Multidisciplinary Team to include: Subject Matter Experts Departments Directly Effected An Administrative representative Individual critical to implementation How to Conduct a Risk Assessment

10. Environment of Care Risk Assessments

11. Review Data: Incident Reports IC Data PI Data Patient Satisfaction Complaints Literature Previous Assessments Safety Risk Assessments

12. New Construction Renovations Environmental Tours Worker Safety – Job Hazard Analysis Targeted Attention

13. Ongoing Environmental Tours Identify hazardous conditions Observe Safety Practices Observe Behavior Eliminate potential hazards Monitor Staff Knowledge Environmental Tours

14. Establish a schedule Conduct annually in non-patient areas and semiannually in patient care areas Create a form or checklist Respond to information Collected Train others in departments to conduct their own mini-tours Formalize Tour Process

16. Assessments that examine the safety risks associated with specific job tasks. NOT required by TJC but required by the Occupational Safety and Health Administration (OSHA). Job Hazards Analysis

17. Review history of accidents, workers comp, work loss days occupational illnesses Conduct job reviews/observations Correct any immediate danger situations Rank jobs: risks posed, likelihood of occurrence and severity of consequences Conducting a JHA

19. Environment plays a key role in prevention of suicide. Deficiencies in the Evironment can contribute to suicide events. Suicide Safety Risk Assessment

20. Conduct Walk throughs Create Behavioral Checklist: Hanging Risks Suffocating Risks Weapon Risks Elopement/Jumping Risks Identification of Suicide Risks

21. Wall protrusions such as fire sprinkler heads, air vent grills – cover with small holed screens Secure lay-in ceiling tiles Removed exposed wires, blind cords, telephone cords, tubings and lines Install anti-suicide doors Remove plastic trash can liners Behavioral Tours Ideas

22. Cont. Use flushed cloth shower curtains attached to above threshold or breakaway rods Use heavy furniture that cannot be easily lifted Install shatterproof glass in windows Remove hangers and closet rods Use sloping hardware Use convex mirrors to prevent blindspots Behavioral Tours Ideas

23. Although many Organizations and their campuses are smoke free, there are conditions where smoking is allowed. Define clearly exceptions to the no smoking policy Insure that practice and policy are the same Monitor policy Develop and implemented strategies to eliminate smoking violations Smoking Risk Assessments

24. Hazardous Materials and Waste Risks Assessments

25. Materials whose handling, use and storage are guided or regulated by local, state or federal directives. Examples: radioactive waste, hazardous vapors, bloodborne pathogens What are Hazardous Materials?

26. Easy! Easy! Easy! Annual inventory hazardous chemicals Identifiy those used How stored Monitoring Disposal Conducting the Hazardous Risk Assessment

27. Department managers should conduct their own inventory Define for Department Managers what materials should be included Create a standardized Form Key Department to spearhead project: Material Department Create a database Conducting the Inventory

28. Identify safer alternatives to hazardous chemicals where possible. Identify better storage practices for chemicals Identify additional security methods when needed. Facilitate the elimination of unneeded or outdated chemicals. Using the Inventory to Lower Future Risk

29. Verify appropriate MSDS. Monitor hazardous gases and vapors associated with dangerous chemicals. Submit the organization’s inventory to the appropriate local, state and federal government agencies. Using Inventory

30. Security Risk Assessments

31. Improve patient and staff safety Improve Health Improve Satisfaction Why perform a Security Risk Assessment?

32. Number and severity of security incidents in an area or department Level of access to area Security hardware present in the area Degree of public traffic through and in an area Potential degree of loss associated with a security issue taking place (i.e. abduction of baby, loss goods) Data for Security Assessment

33. Cont. Risks present in the community Security needs of particular patient population Risks associated with times of day. Risks associated with security sensitive departments Involve managers, various departments, local police when gather information about the environment. Data for Security Assessment

34. Likelihood of Community members to carry a weapon Presence of gangs and gang activity Presence of drugs and money in Facility Facility Shift changes and the times of day Lighting of campus Landscaping of campus Accessibility of panic/alert systems Workplace Violence Considerations

35. Infant and Pediatrics Behavioral Health Alzheimer patients Forensic Patients Special Patient Population Considerations

36. Emergency Management

37. The Plan defines for the Organization a comprehensive approach to identifying risks in order to mobilize an effective response within the organization as well as in collaboration and coordination with essential response partners in the community. What does an EM plan do for an organization

38. Human made Terrorist made Mother Nature made Events that escalate Assessing risks allows the Organization to plan and act during emergencies. The best way is through the Hazard Vulnerability Assessment. Defining Emergencies

39. Planned Structured Flexible Scalable The HVA is a method for evaluating the Organization’s vulnerability to specific hazards. Emergency Management Hazard Vulnerability Analysis

40. Community Planning and Involvement! This assessment requires community involvement for coordination and prioritization within the HVA. Match perspectives of the Organization with the perspectives of the Community. A Big Difference

41. List possible disasters List possible emergencies List pandemics List terrorist event All Hazards Approach

42. Natural hazards Technical hazards Human events Hazardous materials Categorize Hazards

43. Determine Probability of event occurring Evaluate extent of the impact Rank the event Assess current ability to respond Remember: Events never experienced does not mean zero potential for the event. Be objective in evaluation. Assess Impact

44. Short Term Effects Long Term Effects Influx of Patients/Community Changing/ Shifting Probability of Events Considerations during Prioritization

46. Design activities to reduce the risk of potential damage due to the emergency Plan activities to mobilize essential resources and organize efforts Test plans Develop recovery strategies Responding to the Threats Identified

47. Effective HVA’s are linked to the Emergency Operations Plan (EOP). Focuses preparedness efforts Drive the Emergency Drills and Tabletop Exercises Identify Vulnerable populations (dialysis, nursing home, etc.) Accurately understand self-sustainability HVA Uses

48. Fire Safety Risks The Life Safety (LS) Assessment

49. What is it? A proactive tool helping the Organization perform a critical self-assessment of its fire safety risks and current level of compliance with the Life Safety Codes. Statement of Conditions

50. Identifies areas for fire safety focus efforts Assist in developing Plans for Improvement (PFI) Creates timelines and focus for activities Educate staff on the Life Safety Code requirements Remember: All Organizations are required to complete an electronic SOC and BBI. SOC Value