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Finding a high level of noncompliance in accreditation surveys, The Joint Commission (TJC) has made some scoring revisions to Infection Control (IC) standard 02.02.01.
The changes generally add more detailed instructions for surveyors, focus on the highest risk to patients, and note that the hang time of endoscopes will not be assessed anymore as an infection control requirement.
Overall, this standard “requires hospitals to reduce the risk of infections associated with medical equipment, devices, and supplies.” The changes were effective Sept. 1, 2018.
“[IC.02.02.01] continues to be one of the most commonly cited standards listed as noncompliant,” TJC reported.1 “In 2017, 72% of surveyed hospitals and critical access hospitals were found to be noncompliant with this standard.”
The scoring revisions are the result of a Joint Commission comprehensive review of the steps involved in high-level disinfection and sterilization.
TJC will continue to cite facilities as noncompliant if equipment manufacturer instructions are not followed.“Over the next several months, [we] will closely monitor the revisions to ensure consistent scoring,” TJC stated.
Citations that occurred before Sept. 1, 2018, will not be removed. “Hospitals that are in the clarification window or that are preparing their Evidence of Standards Compliance report should document compliance based upon the refined scoring guidelines,” TJC stated.
Here are the TJC revisions for IC.02.02.01:
Previous: Visible bioburden and dried blood found on instruments.
Previous: Enzymatic solution was not applied to maintain moisture on instruments.
Previous: Instruments were not transported from the point of use in a leak-proof puncture-resistant container with the biohazard symbol or color red.
Previous: Instruments in the closed position.
Previous: Instruments are released prior to the biologic indicator being read.
Previous: Items in the high level-disinfected area that are stored in drawers.
Previous: Stored scopes exceeded the hang time.
Financial Disclosure: Peer Reviewer Patrick Joseph, MD, reports that he is a consultant for Genomic Health Reference Laboratory, Siemens Clinical Laboratory, and CareDx Clinical Laboratory. Senior Writer Gary Evans, Editor Jesse Saffron, Editor Jill Drachenberg, Nurse Planner Patti Grant, RN, BSN, MS, CIC, and Editorial Group Manager Terrey L. Hatcher report no consultant, stockholder, speaker’s bureau, research, or other financial relationships with companies having ties to this field of study.