RISK MANAGEMENT APPROACH TO JCAHO COMPLIANCE

1
RISK MANAGEMENT APPROACH TO JCAHO COMPLIANCE
Rose Overturf, CHSP Industrial Hygiene and
Medical Safety Management
2
Definitions

• Hazard
• Control
• Risk (Voluntary/Non voluntary)
• Risk management
• Risk assessment
• Residual risk

3
Hazards in the Environment of Care

• Safety Security
• Physical hazards
• Crime and violence

• Emergency Management
• Internal disasters
• External disasters

• Hazardous materials
• Chemicals
• Biologicals

• Equipment/Facilities
• Medical equipment
• Utility systems
• Building design construction

4
News Headlines - 2001

• Making a Career for Himself
• Chemical Spurs Chaos
• Babies Evacuated at Quito Hospital
• Child Dies in MRI Machine
• Twelve Cases with Six Deaths at a Hospital in
  Paris

5
Risk Management Process

• Meet corporate goals
• Increase patient and employee satisfaction
• Control risk in a cost-effective manner
• Promote regulatory compliance
• Develop solutions when prescriptive standards do
  not exist

6
EC.1.1 Safety Management

• Safety planning includes identifying processes
  for --
• Conducting a risk assessment that proactively
  evaluates the impact of buildings, grounds,
  equipment, occupants, and internal physical
  systems on patients and public safety.

7
Risk Management Process
Identify
Assess
Monitor/ Reassess
Decide
Review
Document
8
Risk Management Process
Identify
Assess
Monitor/ Reassess
Decide
Review
Document
9
Hazard Risk Assessment
High Risk
Low Risk
10
Risk Management Process
Identify
Assess
Monitor/ Reassess
Decide
Review
Document
11
Risk Reduction Strategies

• Eliminate the hazard
• Transfer
• Substitution

• Control the hazard
• Engineering controls
• Administrative controls
• Work practices
• Education and training

• Protect People/Property
• Personal protective equipment
• Protective systems
• Alarms

• Mitigate or Compensate
• Back-up systems
• Vaccines
• Design
• Insurance

12
Risk Management Process
Identify
Assess
Monitor/ Reassess
Decide
Review
Document
13
Documenting Risk Management Decisions

• Safety hazard/issue
• Final decision
• Impact on other organizational functions
• Residual risk and and how you will manage that
  risk

14
Risk Management Process
Identify
Assess
Monitor/ Reassess
Decide
Review
Document
15
Risk Management Process
Identify
Assess
Monitor/ Reassess
Decide
Review
Document
16
Reassessment of Risk

• Change in key personnel
• Renovation or reconfiguration of the work
  area/work place
• New equipment, processes, or services
• New regulations or standards

17
Summary

• Definitions
• Risks in Healthcare
• Risk management process

18
Risk Management Process
Identify
Assess
Monitor/ Reassess
Decide
Review
Document
19
Final Thought

• "Risk Management is the Army's principle
  risk-reduction process to protect the force. Our
  goal is to make risk management a routine part of
  planning and executing operational missions."
• Chief of Staff, Army, July 1995

20
(No Transcript)