EXECUTIVE SUMMARY
The Accreditation Association for Ambulatory Health Care now requires a written risk assessment in infection control (Standard is 7.I.B).
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You must identify risks and rank them.
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When ranking risks, consider the probability of the event occurring; the degree of risk; the potential impact on care, treatment, or services; and how prepared the organization is to respond to the problem.
Beginning this year, the Accreditation Association for Ambulatory Health Care (AAAHC) has a new standard (7.I.B.) requiring a written risk assessment in infection control. The risk assessment becomes the basis for the infection control program for the facility, according to Marcia Patrick, MSN, RN, CIC, surveyor for ambulatory care at AAAHC.
The Joint Commission already requires a written infection control plan based on a risk assessment for hospitals, ambulatory centers, and office-based surgery.
AAAHC now requires its accredited facilities to identify risks and rank them. The accrediting group doesn’t specify how the risk assessment must be done, but it says that a tool will make the process easier.1
AAAHC says that if your facility already has a tool that is working well, you can continue to use it, as long as you rank your risks.1
FACTORS TO CONSIDER
When determining risks, facilities should consider their facility type and community risk, Patrick says. For example, are you a facility that processes scopes and related instruments? Are you in a community with a high number of tuberculosis cases? Other considerations are: your staff and providers; your environment of care; your care practices; your medication practices; disinfection and sterilization of medical equipment, surgical instruments, and endoscopes; surveillance; and your emergency management plan.1
“What we want to see is facilities that identify their risk based on their patient population, their geographic location, conditions in the community — even socioeconomic factors can play a role in terms of education level and education they may or may not need following intervention or diagnostic testing at your facility,” Patrick says.
She says AAAHC would like to see the following issues high on the list of priorities: transmission of bloodbone pathogens, surveillance for healthcare-associated infections, lack of compliance with standards for disinfection of instruments, and environmental cleaning. For example, many facilities have a janitorial service that comes after business hours, but those services need to be monitored, Patrick says. Ensure that janitorial service is using the correct products and that the germicide wet contact time is being met.
USE THESE CRITERIA FOR RANKING
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The risks you identify should be ranked in the order that they will be dealt with. AAAHC says that issues should be prioritized (ranked 0 to 4) based on four criteria:
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What is the probability of the event occurring?
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What is the degree of risk?
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What is the potential impact on care, treatment, or services?
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How prepared is your organization to respond to the problem?1
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The issues with the highest numbers have more risk and should be a higher priority, AAAHC says.
The ranking should take into consideration that some large items might requires budget allocations. For example, the flow of the utility room might be cramped. However the facility might be in office space that has been converted for healthcare purposes, so addressing that issue might require major changes such as tearing down walls. “But we can’t do that tomorrow morning,” Patrick says. “We will have to budget for it.”
WHAT IS THE GOAL?
Each risk should have a goal, which is an over-arching direction of where you want to go, she says.
Improving hand hygiene compliance should be on every organization’s list, Patrick says. Managers should write a measurable objective. For example, the leaders might want to reach 90% to 95% compliance.
“But if you’re at 40% to start, and you say, ‘next month, we’ll be at 95% compliance,’ that’s not realistic,” Patrick says.
Instead, your goal might be to reach 75% by the end of the quarter. Compliance could be measured by secret shoppers, patient query, observations by the supervisor, or another method. If the organization has reach 75% by the end of the quarter, leaders could set a goal for the next quarter of 80-85%. Your goals and objectives become the evaluation of your program, Patrick says.
The written risk assessment is a living document that changes over time, Patrick says. “New issues crop up,” she says. “Old ones sometimes disappear or reoccur.”
REFERENCE
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Patrick M, Accreditation Association for Ambulatory Health Care. Risk Assessment. Connections 2015; November.
