ED Accreditation Update

SHEA assails proposed infection control standards

The Joint Commission has proposed standards revisions that could weaken infection control programs "significantly at a time when health care-associated infections (HAIs) are receiving increasing attention by legislators, payers, and consumers," the Society for Healthcare Epidemiology of America (SHEA) warns.

In a letter submitted to The Joint Commission regarding its ongoing Standards Improvement Initiative (SII), SHEA protested a perceived dilution of infection control standards into the Leadership, Human Resources, and Emergency Management chapters. For example, SHEA 'strongly disagrees' with moving current standard IC.6.10, which deals with an influx of communicable disease patients, into the Emergency Management Chapter.

ED experts note that under the SII, in the area of infection control, ED managers will need to incorporate principles used in cleaning the rest of the institution and ensure an environment for employees and patients that minimizes infectious risks. That requirement will necessitate more methods of incorporating needleless systems, more personnel protective equipment, more cleaning of beds and patient care equipment, more study of infectious situations and incidents, and more patient follow-up. The ED manager will need to have representation at meetings of the infection control committees and will be involved in more efforts that design improved patient care protocols and processes.

Customer satisfaction surveys being revised

The quarterly customer satisfaction surveys of accredited organizations and programs are being revised to provide for a more meaningful assessment of customer perceptions, according to The Joint Commission. ED managers should note that now, in addition to CEOs and the quality liaison, responses will be gathered from nurse and physician leaders.

Currently, surveys are conducted by telephone with CEOs and by mail with the quality liaison of organizations following their organization's on-site survey. Questions cover the benefits of Joint Commission accreditation and the accreditation process, and performance is rated on a five-point scale. The revised scale points will be excellent, good, neutral, fair, and poor. The Joint Commission is focusing on improving customer satisfaction as reflected in the top two rating points — excellent and good — which is in line with current industry practices in tracking customer satisfaction. The following changes are planned for implementation in January 2008:

  • One to five numeric values will be assigned to the scale to help discriminate the ratings and allow for the calculation of mean scores for statistical analysis purposes.
  • Shortened versions of the survey will be conducted between on-site surveys to gather additional information about ongoing customer satisfaction. (For more information, contact Chuck Mowll at The Joint Commission. E-mail: cmowll@jointcommission.org.)

Fire-safety equipment standard revamped

Environment of Care standard 5.40, which addresses fire-safety equipment maintenance, has been revised to be consistent with recently revised requirements of the National Fire Protection Association.

The change requires all smoke and fire dampers installed on or after Jan. 1, 2008, to be operated one year after their installation. In addition, for hospitals and critical access hospitals, the changes extend the timeframe from four years to six years for the ongoing testing of fire and smoke dampers to ensure that they fully close. The standard changes were reviewed and supported by The Joint Commission's Committee on Healthcare Safety and the Professional and Technical Advisory Committees of affected accreditation programs.