JCAHO Update for Infection Control

JCAHO flu vaccine standard would codify CDC guidance

In requesting input whether it should develop a standard requiring seasonal flu immunization, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) made the following key points:

  • Transmission of influenza from staff, students, volunteers, or licensed independent practitioners to patients, clients, residents, or co-workers can create serious population health care problems, especially among those known to be vulnerable to complications in the aftermath of influenza.

  • Vaccination is an important method of preventing influenza and its severe complications. Fewer than 40% of health care workers are immunized each year (unpublished National Health Interview Survey data, Centers for Disease Control and Prevention; 2003). Some health care organizations conduct vaccination programs, but the effectiveness of these programs has not been systematically evaluated.

  • In July 2005, the CDC Advisory Committee on Immunization Practices (ACIP) published a set of recommendations respecting the prevention and control of influenza. The recommendations included the following statement: "Beginning in October each year, health care facilities should offer influenza vaccinations to all workers, including night and weekend staff. Particular emphasis should be placed on providing vaccinations to persons who care for members of groups at high risk for complications. Efforts should be made to educate health care workers regarding the benefits of vaccination and the potential health consequences of influenza illness for themselves, their family members, and their patients. All health care workers should be provided convenient access to influenza vaccine at the work site, free of charge, as part of employee health programs."1

  • ACIP and another CDC committee, the Healthcare Infection Control Practices Advisory Committee (HICPAC), are expected to jointly issue recommendations specific to immunizing health care workers in the near future. The Joint Commission has been in contact with the leadership of these committees and is confident that their proposed and formal recommendations specific to immunization will be congruent with each other.

  • The Joint Commission infection control standards do not specifically require organizations to offer influenza vaccinations to staff, students, volunteers, and licensed independent practitioners. However, standard IC.4.10 requires organizations to refer for assessment, potential testing, and immunization staff, students/trainees, volunteers, and licensed independent practitioners who:
    • are identified as potentially having an infectious disease or risk of infectious disease that can put the population they serve at risk; or
    • have been occupationally exposed to infectious agents.

  • The Joint Commission believes that integrating the CDC’s ACIP and HICPAC recommendations into the infection control standards and the improving organization performance standards would increase patient safety and reduce the number and seriousness of influenza complications among at-risk populations.


  1. Centers for Disease Control and Prevention. Prevention and Control of Influenza. Recommendations of the Advisory Committee on Immunization Practices. MMWR 54(R08);1-40.