3 Key Elements of an Effective Annual Infection Control Risk Assessment

Written by Carole W. Kamangu

This article is updated with links to new resources and opportunities for continuing education credits.

Do you ever feel overwhelmed before starting your annual risk assessment process? Do you feel like your current process is not effective? Are you wondering “Am I even using the correct tools and procedures?”

Many infection preventionists (IPs) who first get started with this process feel the same way. It can indeed feel like a daunting task at first and by not knowing its benefits, it may feel easier to entirely set it to the side. This makes risk mitigation activities much more difficult to achieve throughout the year.

In our free on-demand webinar on this topic, I discussed in more detail why it’s important to conduct the risk assessment annually and how to do it more effectively.

In this article, I’m providing a summary of the key points:

What is the Annual Infection Prevention Risk Assessment?

The annual infection prevention risk assessment is a process that allows infection preventionists to identify risks within their facilities. It helps them remain proactive in identifying gaps in infection prevention practices, allocate resources effectively, and promote patient safety. It also gives IPs a roadmap for the year, requires good organizational and communication skills, and, let’s not forget, patience.

Many new infection preventionists are unsure of what this process entails when they get started for the first time. Those familiar with it may sometimes feel like their current process is ineffective and they're unsure how to correct the issue. Others are not quite sure whether this risk assessment is a regulatory requirement for infection prevention and control (IPC) programs. They certainly don’t believe it will make a difference in their current healthcare practices and believe that things are okay as they are. As advocates for patient safety, okay is not exactly what we aim for.

Now let’s break down what makes an annual risk assessment process effective:

Key Element #1 - Set Specific Goals and Objectives

It’s hard to execute a plan effectively when the end goal is unclear and specific objectives have not been set. The annual risk assessment is the IP’s strategic plan for the year and must involve a data-driven approach to achieve certain goals and objectives.

The IP must identify potential risks and gaps in healthcare practices, set specific metrics to monitor, and the associated objectives that will drive the implementation of appropriate interventions. For this purpose, the IP must have access to data related to infection prevention practice gaps and risks identified within the facility. The IP should then monitor these data throughout the process to assess for improvement.

Key Element #2 - Collaborate with Your Stakeholders

The role of an IP involves several responsibilities that sometimes must be handled simultaneously. For the annual risk assessment process to be effective, the IP must collaborate with department stakeholders. First, the IP must identify department champions who work on the frontline, and then involve them in the process.

By joining forces with frontline staff, the IP not only shares the workload and accountability of implementing best practices with other members of the facility but also benefits from valuable insights from those who directly care for patients. Frontline staff also benefit from this relationship as they learn to better understand infection prevention best practices while feeling empowered as leaders.

Key Element #3 - Maintain a Continuous Improvement Mindset

The annual risk assessment is neither a one-and-done nor a standalone process. It’s not effective if reviewed only once a year and left alone until the next year, or if it’s conducted independently from the infection control work plan and without the involvement of department stakeholders.

Those goals and objectives set at the start of the process must be re-evaluated regularly throughout the year to ensure the effectiveness of the interventions and their completion. In some cases, goals and objectives cannot be met within the same year due to various barriers that can be identified throughout the process. That’s why an evaluation plan with a preset schedule is crucial. By putting such a plan in place, the IP can easily re-evaluate interventions, identify additional gaps, and reset expectations to help re-allocate resources and achieve the set objectives more effectively. The IP should educate department champions regularly to promote a continuous improvement mindset throughout the entire process.

By maintaining ongoing collaboration, tracking data regularly, and keeping a continuous improvement mindset, IPs will notice that the annual risk assessment process becomes more manageable over time and goals can be achieved in the long run.  

Get Started with This Process in Your Facility

Watch our free on-demand webinar to learn some real-life examples of how to conduct the annual risk assessment process effectively. In our next course, Mastering the Infection Prevention Risk Assessment Process in Healthcare, we'll teach practical steps to conduct this process independently in your facility and we'll provide free resources. To take advantage of this course, join the waitlist. This course has been approved for continuing education credits (8 IPUs) by the Certification Board of Infection Control and Epidemiology (CBIC).