Infection Prevention Risk Assessment

Hospitals and Ambulatory Surgery Centers (ASCs) accredited by The Joint Commission (TJC) and other accreditation agencies as well as those having earned “deemed status” by the Centers for Medicare & Medicaid Services (CMS) are requried to have a written infection prevention risk assessment specific to the individual facility.

A risk assessment is conducted to identify real and potential risk factors that create a threat for patients to develop healthcare associated infections (HAIs). A risk assessment assists in setting goals, objectives and strategies for prevention of harm to patients as a result of HAIs in both the inpatient and outpatient setting.  

Development of risk assessments cannot be standardized as they range from simple to complicated, based on many factors. Each facility has unique characteristics and challenges that play a large role in the potential risk to patients.  The assessment assists facilities with identifying their infection prevention challenges and, therefore, developing strategies to overcome them.

ICCS develops individualized risk assessments based on information provided by each facility, and has assisted many facilities preparing to undergo surveys or those that have been through a survey and received deficiencies.

When designing a risk assessment for your facility, various elements are utilized to identify risks. These include, but are not limited to, geographic location, community environment and population served; assessment of services provided; characteristics that increase and decrease risk; prioritized strategies to reduce risk; details of surveillance plans; data analysis; and more.  Creating a grid to evaluate and score the level of harm helps facilities develop priorities, goals and objectives as well as actions to take and follow up.   

The risk assessment is an essential component of the annual infection control plan and must be integrated into the Quality Assurance Performance Improvement (QAPI) program. At a minimum, annual review of the plan and risk assessment is required.

Other expert services provided by ICCS professionals relating to risk assessment include review of current infection prevention plans and, if applicable, development of a corrective action plan for deficiencies.

 

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