Risk Assessment for Infection Surveillance, Prevention and Control Programs

in Ambulatory Healthcare Settings

Explanation of Risk Assessment Tool and the Template for a Risk Assessment Report
This Risk Assessment tool, beginning on page 6, can be used to conduct a facility risk assessment for acquiring and transmitting infections in a variety of
ambulatory healthcare settings. The results of the risk assessment can then be reported using the accompanying template for a Risk Assessment Report (beginning
on page 3). The findings of the risk assessment should be used to provide information about where an organization should focus its infection surveillance,
prevention and control activities.

A facility risk assessment is conducted by identifying and reviewing potential risk factors for infection related to the care, treatment, and services provided and to
the environment of care in a specific healthcare setting. The identified risks of greatest importance and urgency are then selected and prioritized. Based on these
identified risks, facility personnel should develop the organization’s Infection Surveillance, Prevention and Control (ISPC) Plan (i.e., an action plan).

The ISPC Plan should include a goal for reducing the risk of infection associated with each of these identified risks, a measurable objective for each goal, and
evidence based strategies for meeting each of these objectives. The Plan should also identify the personnel responsible for implementing the strategies and include
mechanisms for evaluating the effectiveness of meeting the ISPC Plan’s objectives.

Assessment Process

1. Convene a team to conduct the risk assessment.

2. Identify potential risk factors in each of the following categories:

 Community and populations served
 Potential for specific infection
 Treatment and care practices
 Instrument and medical device cleaning, disinfection and handling
 Environment of care
 Emergency management
 Others identified by the organization

3. Assess and score each potential risk factor based on the following:
a. Potential impact of the event/condition on patients and personnel, determined by evaluating the potential for patient illness, injury, infection, death,
need for admission to an inpatient facility; the potential for personnel illness, injury, infection, shortage; potential to impact the organization’s ability
to function/remain open; and degree of clinical and financial impact.
b. Probability of the event/condition occurring determined by evaluating the risk of the potential threat actually occurring. Information regarding
historical data, infection surveillance data, the scope of services provided by the facility, and the environment of the surrounding area (topography,
interstate roads, chemical plants, railroad, ports, etc.) are considered when determining this score.

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 c. Organization’s preparedness to deal with the event/condition determined by considering policies and procedures already in place, staff experience
and response to actual situations, and available services and equipment.

4. After risk scores are assigned in the three assessment groups, total the numbers in each group to provide a numerical risk level for each event/ condition.

5. Rank the events/conditions from the highest to lowest score in the table provided. Select the risks with the highest scores for priority focus for developing the
annual ISPC Plan. NOTE: Some events/conditions with a lower score may be selected because they are an accreditation or regulatory requirement.

The risk assessment and ISPC Plan should be reviewed and approved by the organization’s quality assurance and performance improvement committee (or other
designated committee). The risk assessment and ISPC Plan should be reviewed annually (and sooner if circumstances change).

_________________________________________________________________________________________________

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 Cover Page for Risk Assessment Report

Risk Assessment Report for Infection Surveillance, Prevention and Control (ISPC) Program
Year: 20__

Organization Name: ________________________________

Date of Report: __________________
Overview

A facility risk assessment for acquiring and transmitting infections should be conducted annually in each healthcare facility. [Note: An annual risk assessment is
required for organizations accredited by The Joint Commission and other accreditation organizations.] The risk assessment provides a foundation for the Infection
Surveillance, Prevention and Control Program because it is used is used to provide information about where an organization should focus its infection surveillance,
prevention and control activities.

This facility risk assessment was conducted by identifying and reviewing potential risk factors for infection related to the care, treatment, and services provided
and to the environment of care in a specific healthcare setting. The identified risks of greatest importance and urgency were selected and prioritized and are noted
below. Based on these identified risks, facility personnel will develop the organization’s Infection Surveillance, Prevention and Control (ISPC) Plan (i.e., an action
plan, with goals and measurable objectives.)

The ISPC Plan includes a goal for reducing the risk of infection associated with each of the prioritized risks, a measurable objective for each goal, and evidence
based strategies for meeting each of these objectives. The Plan also (1) identifies the personnel responsible for developing the Plan and implementing the ISPC
Program strategies and (2) includes mechanisms for evaluating the effectiveness of the meeting the ISPC Program’s objectives.

Assessment Tool

An organizational Infection Risk Assessment tool (below) was reviewed and adapted for use by (Organization name) by the following personnel:

_________________________________________________________________________________________________________________

The Risk Assessment tool was used to identify potential infection risk factors in each of the following categories:
 Community and populations served
 Potential for specific infection
 Treatment and care practices
 Instrument and medical device cleaning, disinfection and handling
 Environment of care
 Emergency management
 Others identified by the organization
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Process

The following personnel conducted the risk assessment:

_______________________________________________________________________________________________________

The group identified, assessed and scored each potential risk factor based on the following:
1. Potential impact of the event/condition on patients and personnel, determined by evaluating the potential for patient illness, injury, infection, death, need
for admission to an inpatient facility; the potential for personnel illness, injury, infection, shortage; potential to impact the organization’s ability to
function/remain open; and degree of clinical and financial impact.
2. Probability of the event/condition occurring, determined by evaluating the risk of the potential threat actually occurring. Information regarding
historical data, infection surveillance data, the scope of services provided by the facility, the environment of the surrounding area (topography, interstate
roads, chemical plants, railroad, ports, etc.), and health department data, are considered when determining this score.
3. Organization’s preparedness to deal with the event/condition, determined by considering policies and procedures already in place, staff experience and
response to actual situations, and available services and equipment.

Ranking of Scores

After risk scores are assigned in the three assessment groups, the numbers in each group were totaled to provide a numerical risk level for each event/condition.
The numerical risk level can range from 0 (lowest vulnerability) to 9 (highest vulnerability). The risk factors (i.e., events/conditions) were then ranked from
highest to lowest risk level in the table below. The risks with the highest scores will be used for priority focus for developing the annual ISPC Plan. NOTE: Some
events/conditions with a lower score may be selected because they are an accreditation or regulatory requirement, or can be quickly and easily implemented.

Distribution of Risk Assessment

The Risk assessment was shared with others, such as the ____________________, to solicit comments. The original group evaluated and incorporated the
comments, as needed, and finalized this risk assessment. The risk assessment will be taken to the (governing body) ______________ and the
______________Committee for final approvals before the Infection Surveillance, Prevention and Control Plan is developed. After final approval of the risk
assessment findings, the ISPC Plan will be developed by __________with periodic reports back to the ____________Committee until the Plan has been fully
implemented.

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Results

A numerical risk level of 9 is identified as the highest perceived potential risk.

Event or Condition Score

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 Risk Assessment for the Infection Surveillance, Prevention and Control (ISPC) Program
Year: 20___
Organization Name: ________________________________
Date of Report: __________________

What is potential impact What is probability of What is organization’s

Numerical
Event or Condition of event/condition on event/condition preparedness to deal with
risk level
patients and staff? occurring? this event/condition?
High Med Low None High Med Low None None Poor Fair Good
Total
(3) (2) (1) (0) (3) (2) (1) (0) (3) (2) (1) (0)

COMMUNITY & POPULATIONS SERVED:

EMERGING INFECTIOUS DISEASE

POTENTIAL FOR SPECIFIC INFECTION:

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 What is potential impact What is probability of What is organization’s
Numerical
Event or Condition of event/condition on event/condition preparedness to deal with
risk level
patients and staff? occurring? this event/condition?
High Med Low None High Med Low None None Poor Fair Good
Total
(3) (2) (1) (0) (3) (2) (1) (0) (3) (2) (1) (0)

CARE PRACTICES:

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 What is potential impact What is probability of What is organization’s
Numerical
Event or Condition of event/condition on event/condition preparedness to deal with
risk level
patients and staff? occurring? this event/condition?
High Med Low None High Med Low None None Poor Fair Good
Total
(3) (2) (1) (0) (3) (2) (1) (0) (3) (2) (1) (0)

INSTRUMENT & MEDICAL DEVICE CLEANING, DISINFECTION & HANDLING

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 What is potential impact What is probability of What is organization’s
Numerical
Event or Condition of event/condition on event/condition preparedness to deal with
risk level
patients and staff? occurring? this event/condition?
High Med Low None High Med Low None None Poor Fair Good
Total
(3) (2) (1) (0) (3) (2) (1) (0) (3) (2) (1) (0)

ENVIRONMENT OF CARE:

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 What is potential impact What is probability of What is organization’s
Numerical
Event or Condition of event/condition on event/condition preparedness to deal with
risk level
patients and staff? occurring? this event/condition?
High Med Low None High Med Low None None Poor Fair Good
Total
(3) (2) (1) (0) (3) (2) (1) (0) (3) (2) (1) (0)

EMERGENCY MANAGEMENT:

OTHER:

1. Potential impact of the event/condition on patients and personnel: determined by evaluating the potential for patient illness, injury, infection, death, need for admission to
an inpatient facility; the potential for personnel illness, injury, infection, shortage; potential to impact the organization’s ability to function/remain open; and degree of clinical
and financial impact.
2. Probability of the event/condition occurring: determined by evaluating the risk of the potential threat actually occurring. Information regarding historical data, infection
surveillance data, the scope of services provided by the facility, and the environment of the surrounding area (topography, interstate roads, chemical plants, railroad, ports,
etc.) are considered when determining this score.
3. Organization’s preparedness to deal with the event/condition: determined by considering policies and procedures already in place, staff experience and response to actual
situations, and available services and equipment.

Developed by: K. Arias, M. Patrick, K. Delahanty and S. Odachowski

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 GOALS AND OBJECTIVES

OBJECTIVE
RISK EVENT/ CONDITION GOAL (measurable, includes
timeframe for completion)

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RISK EVENT/ OBJECTIVE
GOAL (measurable, includes STRATEGIES IMPLEMENTATION
CONDITION timeframe for completion)
Respon-
Method for Evaluating
sible
Person(s) Effectiveness

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