The Joint Commission does not require organizations to include all surgical procedures in their surveillance for surgical site infections, but they may use risk assessment results to guide prevention efforts. Here are five things to know.
1. The Joint Commission recommends periodically conducting risk assessments to identify high-risk procedures and settings in an effort to prevent surgical site infections. These assessments may help organizations target certain areas for surveillance.
2. The Joint Commission does not mandate a particular risk assessment model. Organizations may conduct a proactive risk assessment, which evaluates sequencing of events, actual or potential risks, and failure or points of vulnerability. This model prioritizes areas for improvement based criticality of care, treatment or services provided.
3. Organizations may choose to use other risk assessment tools that better suit their facility's needs, such as a root cause analysis, failure mode and effect analysis or a plan/do/check/act process. It is acceptable to implement combinations or variations of these models.
4. Any risk assessment should focus on all components of the surgical process, including staff knowledge and competency, surgical attire and patient education.
5. Surgical procedures carried out at all locations should be incorporated into the organization-wide quality assessment and performance improvement program.