Healthcare Infection Prevention

Widespread clinics: Duke ICPs hit the road to ensure Joint Commission accreditation for medical offices

Cool tool: A handy rounds form takes the pain out of the process

With an accreditation survey looming and 45 newly affiliated clinics over a 120-mile radius seeking a first-time stamp of approval, it was time for a road trip. "I think our farthest clinic is almost two hours away," says Sheila Vereen, RN, BSN, an infection control professional at Duke University Health System in Durham, NC. "The challenge was being able to get there, meet with them, do environmental rounds, and give them feedback on the spot."

The Joint Commission for Accreditation of Healthcare Organizations was coming to do a survey in a matter of months, and the plan was to accredit the 45 private physicians offices and christen them the Duke University Health System Private Diagnostic Clinics. "They were never Joint Commission-certified," she says. "So in order to get them ready for meeting the standards, we had to divide up the work, go and visit these areas, and give them recommendations on improvements to meet the standards."

To do so, the Duke ICPs had to become inspectors themselves, so they developed a concise environmental rounds form to make the process as painless as possible. (See form.)

Common deficiencies identified

Checklist in tow, they came in looking for compliance in seven categories: hand washing, storage of supplies, medication areas, linens, universal (standard) precautions, housekeeping, and refrigerators. "The common areas of deficiencies were in the area of storage of supplies, medication areas, and storage of linens," Vereen says. "You can’t have any boxes on the floor with supplies in them. You want to get your supplies shelved and put away as quickly as the vendor brings them."

A second visit was deemed necessary for 36 of the 45 clinics, and compliance improved dramatically in all identified areas. "Some of them we had to revisit if they really needed assistance getting ready," she says. "We had to make sure that the standards were being met."

In doing so, Duke is ahead of the national trend. As we reported in Healthcare Infection Prevention, August 2002, p. 1, the vast majority of physician offices and ambulatory centers — where an increasing array of invasive procedures is being performed — have virtually no accreditation oversight. (See Hospital Infection Control, August 2002, under archives at

And how did the survey go? Zero deficiencies were identified. "We had an interview during the survey and we shared the format in which we did the environmental rounds with the [Joint Commission] surveyors," Vereen says. "They thought it was a good idea; as a matter of fact, they wanted a copy of the form to share with other institutions," she explains. To ensure ongoing compliance, a part-time ICP is still on the road, visiting the clinics intermittently to ensure they are up to speed on any policy changes and new infection control guidelines.