The first key to effective infection prevention strategies is knowing how to choose your battles. In any surgical facility, there are countless threats to consider — both within and beyond your control. Sure, you'd like to be able to address them all, but since resources are always finite, you want to focus on the most serious threats — those that are more likely and more profound in their potential consequences.

That's what developing a risk assessment is all about: determining how best to focus your attention and resources. Of course, if you're accredited or accepting reimbursements from CMS, risk assessments are required. But I find that a lot of people are confused about how to conduct them. When I teach classes on developing risk-assessment strategies, I always ask how many attendees have been in their current roles for less than 2 years. Usually almost every hand goes up.

Since situations that loom as serious threats to one facility may be non-threats to another, you need to be able to analyze and prioritize. One approach is to score each risk that exists based on 3 criteria. Consider, for example, 2 potential types of risks and the impact they could have: poor hand hygiene compliance and sharps injuries.

1. How likely is it to occur in the next 12 months?
0virtually no chance 1unlikely 2medium likelihood 3very likely

If, for example, you've observed that hand hygiene compliance is poor — say, 50% — it's very likely to continue to be poor, unless there's an intervention. Meanwhile, if you have a high-volume, high-pressure facility, there's probably at least a medium likelihood of a sharps injury occurring in the next 12 months.

2. What is the degree of potential harm if it occurs?
0little or no harm 1temporary harm 2permanent harm 3life-threatening harm

The degree of potential harm resulting from less-than-optimal hand hygiene might be a judgment call, depending in part on how poor compliance is and what kinds of procedures you're doing. A sharps injury could conceivably be life-threatening, but that's unlikely. Temporary harm is the most likely scenario, but permanent harm certainly isn't out of the question.

3. What is your current level of preparedness and/or to what degree do you need to make changes in care, treatment or services to address the risk?
0well prepared/no changes needed 1mostly prepared/few changes needed 2somewhat prepared/some changes needed 3poorly prepared/major changes needed

If sinks, soap and paper towels are properly located and alcohol hand rub dispensers are readily available, the number of changes required to address hand hygiene is low. But if major construction would be needed to add sinks and install alcohol dispensers, the need for changes would be high. If your staff is well educated on the risks associated with sharps injuries, and you've taken steps to prevent them (using specially designed equipment, instituting "passing zones," conducting in-services), you'd score this a 0 or 1. If you haven't, it might be a 2 or 3.

Adding up the scores
Add up the numbers and you get a clearer idea of where you should be focusing your attention. High numbers suggest a higher priority. Let's say the probability of a sharps injury is a 2 — fairly likely. Additionally, the degree of risk is also a 2 (potential for permanent harm). But let's assume you've gone to considerable lengths to address the situation (1 point). The total would be 5.

Now let's say hand hygiene compliance is poor, based on your observations (3 points). The potential harm is a 2 (though it could be higher or lower depending on your procedures). Generally, you have good product available and it's located in areas where it's convenient to all levels of staff; it's just a matter of getting staff to use it. That's 1 more point, giving it a total of 6, and making it a higher priority.

Improvement strategies
Your risk assessment should be a springboard for action, leading to both goals ("improve hand hygiene compliance" "reduce the risk of SSIs") and measurable objectives. Measurable objectives should cite specific results to be achieved over specified time periods: "Hand hygiene compliance will be 90% or better by the end of 2Q 2015, as measured by 'secret shoppers.'" All goals must be measurable and have dates associated with them so the following year you can objectively measure your program's impact.

You can also incorporate your objectives into management and employee objectives, and monitor them as performance goals. In doing so, you make the goal everyone's and not just "an infection-prevention goal."

Finally, once you've prioritized your risks, it's best not to take on more than 3 or 4 major goals to start. But have a few that are quick fixes — ones that will require minimal time and resources but will make a difference. Those are good for morale. Don't avoid the big ones because they seem too daunting, but if need be, back-burner them until you cultivate more support from administration and staff and gain more experience as to how your organization initiates and proceeds with change.