From the case study:

Develop a Risk Management Plan:

-Identify 5 major risk for your project

-Assess likelihood, impact, detection

-Rank per priority

- Finalize a Risk Response Matrix.

Case Study- Preparing Hospitals to Effectively Respond to Bioterrorist Attacks Source: Patriciat L. Shaw and Darcy Carter, Quality and Performance Improvement in Healthcare, Sixth Edition, AHIMA press. Chapter 18 Managing Healthcare Performance Improvement Projects, Real-Life Example. The Joint Commission has accreditation requirements to include specific plans for response to bioterrorism. The Center for Disease Control and Prevention, Health Resources and Services Administration, and the Department of Homeland Security work together to ensure that state and local health departments, hospitals, and other health agencies are able to mount a collective response to bioterrorism events. A 150-bed community hospital, located approximately 35 miles from a large medical center in another county, has been approached by the county health officer to develop a bioterrorism response plan. Although the hospital has conducted annual disaster drills in compliance with previous Joint Commission standards, the drills were mass casualty exercises based on the scenario of a major fire in an industrial setting, natural disasters or a transportation accident involving large numbers of inured patients. Previous exercises did not address exposure of large numbers of patients to biological or chemical agents due to a terrorist act. The hospital administrator and the county health officer agree that there is a need to enhance and broaden the scope of disaster planning to include issues that would required significant decontamination of patients or strict quarantine of patients exposed to biological or chemical agents. The hospital administrator has agreed to appoint a project team that will work with the county health officer to expand the existing disaster plan to include bioterrorism threats. The county health officer has authorization to spend funds from the Department of Homeland Security to purchase supplies and equipment that the hospital would need in the event of an attack. This includes items such as decontamination equipment and personal protective equipment (PPE) for hospital personnel assigned to bioterrorist response teams. To qualify for the funds, the hospital must coordinate with the county health officer and develop a plan for responding to a bioterrorist attack using the framework developed by Homeland Security, called the National Incident Management System, adoption of which is a condition for federal preparedness assistance and fudging. For years, the hospital had been using the Incident Command System to orchestrate a response to local disaster situation, but now the response plan needs to be broadened to work with multiple agencies in the region in order to manage the possible dispersed nature of a biochemical terrorist event. Because federal funding is involved, the plan must be complete and in place within 12 weeks or the funds will be withdrawn and reallocated to other regions of the country. The hospital is scheduled for a Joint Commission survey in about 9 months and additional incentive to complete the project in a timely manner.During the initiation phase of the project, the hospital administration and the county health officer agree upon the mission to develop an implementation plan for policies and procedures that prepare the hospital to effectively respond to an external bioterrorist attack involving biological or chemical agents. The combination of individuals select3ed for the hospital project team is based on ensuring that all of the required components of the Incident Command System under unified command are represented. The hospital administration has decided to appoint the director of emergency services as the hospital project team leader. The team leader will be expected to 2 work closely with the county health officer along with the leadership of fire, police, emergency medical services, and public works agencies in directing the team's activities. The county health officer will be the overall coordinator of the regional multidisciplinary project team. Under a unified command, agencies will work together through the designated members to analyze intelligence information and establish a common set of objectives and strategies for a single Incident Action Plan. In the case of a real bioterrorism event, it would be likely that the director of emergency services would fill the role of operations sector chief for hospital incident activities. The director of health information services is selected to represent the functions of the public information officer (PIO). The PIO is responsible for interfacing with the public and the media and with other agencies and organization with incident related information requirements. The PIO develops accurate and complete information on the incident's cause, size, current situation, and other matters of general interest for both internal and external consumption. The infection control nurse's activities become even more important in a bioterrorist attack in collecting data and training staff on procedures that will control further spread of disease and illness from a patient infected by a biologic agent. The infection control nurse is selected for the project team to support the operations section chief with technical information and processes for handling the bioterrorism event. The director of physical facilities, in support of the operations section chief, is responsible for ensuring that portable decontamination tents and other equipment can be unstored and deployed efficiently in the case of a real event. He or she also must be able to effectively control heating, ventilation, and air conditioning systems that can be shut down and secured in the event of a bioterrorist threat to the hospital's internal environment from contaminants floating in the external air.As part of the initiation phase, the hospital administrator brings the selected members of the project team together for orientation. At this point, the planning phase begins. The team will meet to brainstorm and identify problems. The project list of activities (TABLE 1), depicts the four phases of the project and the tasks to be accomplished in each phase. In the planning phase, the subtasks are assigned to individual team members based on their areas of expertise and responsibility. As team members bring information and expertise back to the team, the plan begins to take shape and the team prepares to move into the execution phase. The predominant tasks of the execution phase are writing the final draft of the plan and training staff in preparation for future exercises and the possibility of an actual terrorist attack. During the last phase, closure, the team and hospital leadership evaluate the results of the project. The rehearsal exercise will be documented so that the lessons learned can be applied to opportunities for continued improvement and demonstrate to the Joint Commission surveyors that an annual meeting the new standards has been conducted