Explain the role of accreditation in mitigating risk compliance issues.  Provide an example of a health care organization that was placed on probation by its accrediting body or by CMS within the last 3 years for a risk compliance issue. What caused the probation or loss of accreditation and how could it have been prevented?

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The Enterprise Risk Management Domains are a great tool to assess and coordinate surveillance plans in order to operate a hazardous free facility. I work in an Alzheimer’s and Dementia facility; in addition to the general risk plans, we have to add behavioral, fall prevention, and special disaster preparedness due to the patients’ inability to ambulate and verbalize needs. I will choose the two domains that we emphasized the most Clinical & Patient Safety and Environmental- and Infrastructure-Based Hazards. Clinical & Patient Safety – The facility prepares diligently to identified and respond to threats that may affect the overall health of the residents; they have designated team members to monitor patients outcomes in regards to antibiotic use, infection control and Healthcare Acquired Infections (HAI), that team member is called an infection preventionist, she is in charge of performing rounds to each department (laundry, nutrition, activities, nursing, etc.) to ensure they are in compliance with infection control guidelines and protocols. Infrastructure-Based Hazards – The environmental and maintenance team is of great support when it comes to environmental hazards, disaster preparedness, and patient safety; the facility is designed to protect the resident by preventing injuries, such as falls, drowning, choking, and aspirating. We are a lockdown unit to prevent elopement, the sinks are in special units to prevent patients from falling or ingesting the soap, their rooms have limited furniture, and the patios are gated with locks. I believe their plan is very effective in mitigating risk; I will suggest more assistive staff; the facility is against all types of restrains, meaning that if a patient becomes aggressive and combative, we have to handle the situation by other means, and it can be time-consuming. The quality improvement projects at the facility require a different approach due to the special infrastructure, the population, and the limited staff.

Catalyst, N. (n.d.). What Is Risk Management in Healthcare? Retrieved November 18, 2020, from https://catalyst.nejm.org/what-is-risk-management-in-healthcare/

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