A systematic approach to an infection control programʹs risk assessment

ISSUE: The 2005 Joint Commission standards for infection control (IC) require organizations to conduct ongoing risk assessments in designing an IC program. In reviewing our program against the new standards, we noted that while our targeted nosocomial infection surveillance activities were based on a formal risk assessment, the assessment for our other routine IC rounding activities was less formal. We knew that we had considered risks in developing our current rounding process, but we were concerned that we might have difficulty showing a surveyor the basis for our rationale. PROJECT: To address this concern, we developed an infection control risk assessment tool to help prioritize our rounding activities. This tool quantifies the risks to patients and healthcare workers (HCWs) and considers both internal and external environmental risks. Risks to patients and HCWs are assessed for each location and are assigned a value from 1 to 4, with 1 having the least risk and 4 having the greatest risk. These 2 values are multiplied together to give a total risk score for the area. This score is then used to define the frequency of our routine surveillance rounds. Areas are reassessed using this tool annually and whenever new procedures are introduced and new locations are opened. RESULTS: We identified 86 areas within the medical center and its satellites and calculated a risk score for each area. These scores ranged from 1 to 16. The values were divided into 4 categories, and the frequency of the IC rounds was determined by the category in which the area fell. Through this process, we identified some areas that warranted more frequent rounds than in the past and other areas that we had been visiting merely out of convenience. Although consideration to risks had been applied to the previous surveillance plan, this strategy allowed IC to prioritize tasks and make better use of its resources. LESSONS LEARNED: While we felt that our previous surveillance plan had been based on a formal risk assessment, we now recognize that it had missed some critical areas and/or underestimated their IC risk. This quantitative tool has helped guide our activities, making the IC staff more visible throughout the organization. The IC staff members are now able to focus their infection prevention efforts on the areas with the greatest hazards.