What do surveyors want to see at your hospital?

JCAHO places renewed emphasis on IC

Surveyors enter a hospital with a unique set of priorities that relate to the hospital's needs and attributes. But as infection control issues rise to the forefront, employee health may receive a greater focus. What do surveyors expect? Hospital Employee Health posed that question to Nancy Kupka, DNSc, MPH, RN, project director in the division of standards and survey methods at the Joint Commission on Accreditation of Healthcare Organizations. She offers advice as hospitals prepare for unannounced surveys.

• What steps does the Joint Commission expect hospitals to take in response to the national pandemic influenza response plan?

We do not have any specific requirements related to that plan or to pandemic influenza. We do have standards in environment of care and infection control related to emergency management. IC 6.10 states, "As part of its emergency management activities, the hospital prepares to respond to an influx or the risk of an influx of infectious patients."

Determine generally what you're going to do and prepare for how you're going to do it. The organization is also required to determine how it's going to keep abreast of current information, how you're going to disseminate critical information to your staff, and what resources there are in the community.

IC 4.10 requires organizations to develop interventions, such as screening employees for exposure and/or immunity to infectious diseases that they may come into contact with in their work.

We also learned from the SARS epidemic that education and protection of health care workers is vital. When employees felt they were protected, they came to work. For an organization to stay viable, they're going to have to get their employees to come to work.

The response to an influx of infectious patients may vary based on an organization's resources. For example, smaller organizations may decide to close to new patients, or a hospital may join forces with a hospital across the street.

• Although surveys can vary greatly, is there an infection control/employee health issue that will be common among surveyors?

They will ask, "How have you implemented the [Centers for Disease Control and Prevention] hand hygiene guidelines?" They will look to see that there's evidence of hand hygiene when we follow tracer patients through the system. If there's a sign that says a patient is on respiratory precautions, we would expect to see a box of gloves and masks available.

• How will surveyors approach the issue of annual respirator fit-testing? [Annual fit-testing of N95 respirators is required by the U.S. Occupational Safety and Health Administration, but federal enforcement of the rule has been halted by congressional action.]

We don't have a standard related to fit-testing of respirators. However, we do have a standard related to complying with state and federal regulations. We don't really have a position other than if it's required, we would expect to see it.

• Joint Commission surveyors have typically reviewed the TB screening of employees. In the new TB guidelines released by the CDC, low-risk hospitals will no longer need to perform annual screening. How will this change surveys?

We will provide some education to surveyors about the new guidelines. Ultimately, the organization still has to identify the level of risk [and review it on an annual basis]. I don't think it will impact surveys, at least initially.

• One of the 2006 National Patient Safety Goals is to "reduce the risk of health care-associated infections." Has the Joint Commission's approach to infection control changed?

A major revision of the infection control standards went into effect in January 2005. Previously, there was a huge emphasis on surveillance. There's still an emphasis on surveillance, but we tried to move the standard toward an emphasis on implementation — identifying problems and getting on top of them.

We expect leadership to be involved, to be part of the process. We have a renewed emphasis on infection control. I think the world has a renewed emphasis on infection control. We've also significantly changed our survey process to look at issues in infection control. We're continuing to look at evolving the standards and the survey process as it relates to infection control.