What is involved in a TJC Survey re: a risk assessment of the Environment of Care (EOC) and leadership’s role in optimizing results

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by Randall B. Charpentier

Hospital signIt is the responsibility of the facility to conduct a physical risk assessment of the physical environment to evaluate hazards and develop protective measures associated with various tasks performed in each environment within the hospital, off-site facilities and campus grounds. Facilities do this in preparation for TJC surveys of the environment of care (EOC) and to identify and fix problems.

During a TJC survey, they review the impact of the environment of care on the ability of the organization to perform clinical and business activities. The impact may include disruption of normal functions or injury to individuals.   TJC surveyors will evaluate the risk from a variety of functions, including structure of the environment, from the performance of everyday tasks, workplace violence, theft, infant abduction, and unrestricted access to medications.

An initial risk assessment is required whenever a new building is constructed, or the facility purchases an existing building or an area undergoes significant renovation or conversion of use or services. A risk assessment is required for all areas not having one completed within the last 3 years. At least every 18 months, the hospital conducts one high risk process and a proactive risk assessment. (LD.04.04.05EP10)

Most Risk Assessments that I’ve observed focus on the following:

  • Physical tour of the facility
  • Regulatory compliance (e.g., OSHA, NFPA® The Joint Commission®, Department of Health)
  • Review of annual incident and accident statistics
  • Results of root cause analyses
  • Results of annual proactive risk assessments of high-risk processes
  • Credible external sources (i.e. Sentinel Event Alerts).
  • Review of at least the past twelve (12) months EOC Committee    minutes
  • Environmental Tours reports
  • Interviews with department heads & staff
  • Best demonstrated practices.

So what data should you use?

I have found that the most useful data is the physical and health hazards that are present during the daily operation in a busy facility. This data is usually captured on your OSHA 300 log, worker’s comp. insurance company loss runs, and your internal incident recording system that documents patients/staff and visitor incidents/accidents and injuries. The environmental rounds data may not be indicative of the actual hazards/risks in your facility because surveying patient care areas twice a year, and non-patient care areas once a year cannot adequately identify and correct the hazards that patients/staff and visitors face daily. In addition, work order systems alone can’t differentiate safety from non-safety hazards. And neither can non-skilled safety professionals.

A typical Risk Assessment 

Typically, a cross-disciplined team of Facility, Human Resources, Risk Management, Occupational Health, Security, Environmental Services and others meet on several occasions to examine the EOC disciplines:

  • Safety
  • Security
  • Fire & Life Safety
  • Hazardous Materials & Waste
  • Medical Equipment
  • Utilities
  • Emergency Management:

Risk categories may include: Asbestos, Electrical Equipment, Noise,   Workplace Violence, Theft, Egress, Detection, Suppression, Hazmat Chemicals Toxics/Corrosives/Flammables, Loss of Life Support, Loss of Primary/Emergency Power & Have drills been completed.

Can a cross disciplined-team adequately address hazards other than the obvious ones?

Most often, the team will numerically rate the risk (i.e. Low 1, Medium 2, eyewashHigh 3 etc.) by department and risk categories listed above and based on their collaborative efforts, and experience on tours that include the discovery of code/med cart in the corridor, stained ceiling tile, chemicals stored under a sink, and eye wash behind a locked door, right?  The obvious concerns that many surveyors look for during a typical survey.

I’ve experienced checklists for Environmental Rounds that document the obvious hazards listed above with work orders cut, complete, and emails sent to Dept. Managers to address. If this process is an effective one, wouldn’t they reduce their accident/injury/illness rate in half? Evidence has suggested that this method may not be the most effective as healthcare continues to be one of the most dangerous industries to work in.


Occupational Safety and Health Administration

Bureau of Labor Statistics

There is evidence that when the appropriate data is utilized, a healthcare facility can have a huge impact on reducing accident/injury/illnesses associated with a major loss source.

Such data includes patient/visitor/staff incidents, identifying root causes & targeting loss sources/corrective actions that eliminate potential for recurrence such as patient transfers, slips, trips, falls, contusions, violence and needlesticks.  A recent demonstration noted that when a loss source is targeted such as patient falls, and a collaborative effort and commitment is employed, significant impact can be achieved. “Using a method they call Robust Process Improvement, five participating hospitals were able to decrease the rate of falls with injury by 62percent”.


When Senior Healthcare Executives begin to examine how many lives are being impacted, and dollars being spent on addressing patient/staff/visitor incidents, they may actually focus on injury/incident and expense reduction.  A total commitment to risk reduction will often result in improved morale, decreased injury/incident costs, positive cultural impact and a safer environment for your patients, staff & visitors.

CMS is measuring safety and quality in healthcare facilities basing reimbursement on your outcomes. Do you measure up? If not, you should conduct a risk assessment. Are YOU compliance or results driven? You may contact HSNE/Randall for additional information:  rcharp@hsnellc.com., www.hsnellc.com, or linkedin profile https://www.linkedin.com/nhome/?trk=

Randy CharpentierRandall is a 20 year experienced, safety and risk management consultant specializing in healthcare compliance.   Project experience ranges from leading teams on the construction of the west coast space shuttle project, working internationally & domestically for leading environmental engineering firms conducting real estate assessments involving occupational and environmental risks, assessing business operational risks concerning commercial insurance policies, and reducing/eliminating exposures/hazards, to leading world renowned, top ten/one hundred community based & BioMedical Research/Teaching hospitals, with development and management of environmental health and safety management programs. HSNE’s/Randall’s passion is keeping patients, staff and visitors safe in a healthcare setting.

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