The Joint Commission Update for Infection Control

Tips to conduct your annual IP risk assessment

Bring in key partners in setting priorities

Under standard IC.01.03.01, The Joint Commission requires that the hospital identifies risks for acquiring and transmitting infections. This is done primarily through an annual risk assessment, which forms the bedrock for the infection prevention program activities, emphasized Barbara M. Soule, RN, MPA, CIC, Joint Commission practice leader in infection prevention and control services.

"The risk assessment is the foundation of your infection prevention program," she said recently in Chicago at a Joint Commission infection control conference. "If you do it well and come up with your priorities it provides focus for your activity and resources."

Soule offered the following tips and key elements of an infection prevention risk assessment:


Form partnerships with:

  • Key stakeholders, e.g., physicians, nurses, technicians, laboratory, special support services, administration to provide data and information, experiences, concerns reflecting their responsibilities, e.g., ICU staff, occupational health, biomedical services, risk management.
  • Those who have the information you need.
  • Opinion leaders in the organization.
  • Leadership for support and endorsement.


  • Create a team to help analyze the information from the assessment
  • Engage three to five key staff to work as a team on the assessment
  • Patient safety and performance improvement staff or committees to assist

Gather Data and Information

  • Organization Data
  • Gain access to key reports in the organization, e.g., services provided, populations served and characteristics and volumes, special environmental issues.
  • Tap into organization data (medical records, lab records, admission and discharge numbers
  • Review IC program surveillance data

Scientific Data

  • Review the literature for new trends in infection control journals and other sources
  • Link to key web sites (e.g., health departments, CDC, APIC, SHEA, IDSA)

Community Data

  • Connect with the local health department to identify trends that may affect infection risk in the facility
  • Issues of emerging pathogens and bioterrorism plans

Systematic Methods and Templates

  • Develop a systematic way of looking at data
  • Turn qualitative data into quantitative when possible
  • Develop a ranking scheme to determine highest priorities
  • Team ranks data to determine priorities

Educate Others to Assist in Assessment

  • Provide support and guidance for others to perform their risk assessments:
  • Provide an educational session
  • Share organization's IC data from surveillance, outbreaks, morbidity, mortality
  • Design a simple template
  • Create ease of performing and submitting information

Disseminate the Information

  • Market the risk assessment importance and share results.
  • Develop concise, clear report with key points highlighted
  • Acknowledge those who participate in the process