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Executive Summary Joint Commission Accreditation Audit

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|SECTION: |EFFECTIVE DATE: October 1, 2006 |
|SUBJECT: |PAGE 1 of 8 |
|Proactive Risk Assessment Policy | |

Scope:
This policy applies to all direct and indirect patient care processes, departments, and facilities of ABC Medical Center (ABC).

Objective:
To establish a comprehensive, proactive risk assessment process to evaluate the potential adverse impact of direct and indirect patient care …show more content…

The Patient Safety Officer will schedule departmental and area risk assessments by determining if any areas not scheduled for an initial assessment in a given year have had significant changes that would indicate the need to conduct a risk assessment in that area.

3. Once a potential risk is identified, the Patient Safety Officer will present the issue for discussion at the next Patient Safety Committee meeting.

4. The Patient Safety Committee will discuss the risk and if appropriate, appoint a risk assessment team to analyze the risk and report their findings at the next Patient Safety Committee meeting.

5. The Patient Safety Officer will train the risk assessment team members on the proactive risk assessment process and how to conduct a proactive risk assessment, including the assessment of risk, itself.

6. The risk assessment team will conduct an inspection of the department/area being assessed for risk or observe the process being assessed for risk in action. The members of the risk assessment team will individually document their findings on the “ABC Proactive Risk Assessment Worksheet” (Attachment A). To determine the appropriate score for each identified risk, the reviewer will consider information obtained through a physical tour of the facility, review of annual incident

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