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.
New Scoring
Here are the TJC revisions for IC.02.02.01:
Previous: Visible bioburden and dried blood found on instruments.
New Scoring:
- Wiping/flushing of soiled instruments is not observed during a case in the operating room or procedure room and it is clinically appropriate.
- Item that is ready for use on a patient is visibly soiled.
Previous: Enzymatic solution was not applied to maintain moisture on instruments.
New Scoring:
- There is no process for keeping used instruments moist.
- Manufacturer instructions for products used to keep instruments moist were not followed.
- The facility policy for keeping instruments moist was not followed.
Previous: Instruments were not transported from the point of use in a leak-proof puncture-resistant container with the biohazard symbol or color red.
New Scoring:
- Sharps are being transported in a manner that violates OSHA requirements (e.g., sharps not placed in puncture-resistant container that is red or labeled biohazardous).
- Nonsharps are transported in a way that could lead to contamination of staff or other people.
Previous: Instruments in the closed position.
New Scoring:
- Packaged instruments awaiting sterilization are in the closed/ratcheted position.
- Items that have just undergone sterilization are on the trolley or in the sterilizer in the closed/ratcheted position.
- Items in preparation and packaging that have come through the washer or pass-through window have not been disassembled in accordance with manufacturer instructions.
Previous: Instruments are released prior to the biologic indicator being read.
New Scoring:
- Routine sterilizer monitoring with a biologic indicator required by the state or per evidence-based guideline is not followed and recorded.
- Nonimplant load is released without physical monitoring of cycle and external and internal chemical indicators.
- Implant loads are released without routine sterilizer monitoring, a biologic indicator, and a type 5 integrating indicator (“integrator”).
- The biologic indicator was not read before implant release (unless allowed in emergent situations by facility policy and policy was followed).
Previous: Items in the high level-disinfected area that are stored in drawers.
New Scoring:
- Container or location of storage is visibly soiled, or staff are observed contaminating other high level-disinfected products.
- Storage is not consistent with the item’s intended use (e.g., items that require a minimum of high-level disinfection may be stored in a way that protects from contamination even if they were sterilized).
- Item is not stored in accordance with manufacturer instructions for use (IFU).
- Item is not stored in accordance with facility risk assessment/policy if no guidance was provided by the item’s manufacturer IFU.
Previous: Stored scopes exceeded the hang time.
New Scoring:
- Facility is not following manufacturer IFU for drying.
- Facility is not following manufacturer IFU for frequency of reprocessing.
- Will NOT score any finding related to hang time under IC standards.
- Joint Commission. Accreditation and Certification: 4-1-1 on Survey Enhancements: New scoring revisions for IC.02.02.01 now in effect. September 5, 2018: https://bit.ly/2wTYkzg.
