What JCAHO’s new IC standards mean for you

The buck will stop at the administrator’s desk

The Joint Commission on Accreditation of Healthcare Organizations has issued new infection control standards for 2005, emphasizing at a conference in Chicago that hospital executives — not quality managers or infection control practitioners — are going to have to take ultimate responsibility for enacting them.

"There are some people who, quickly scanning the revised standards, have concluded that they are really nothing more than old wine in new bottles," said Dennis O’Leary, MD, president of the Joint Commission. "However, if you are an accredited organization, that would be a really grave miscalculation. These standards bell the cat. They put leaders of health care organizations on notice and on point. If things go south for any reason . . . [there is] no opportunity or permission to defuse the responsibility."

In addition to the 2005 standards, some 400 attendees at the Joint Commission’s infection control conference discussed a 2004 JCAHO patient safety goal of reducing nosocomial infections. The actions culminate the Joint Commission’s aggressive new interest in infection control, which now has become a strategic cornerstone in its overall mission to improve patient safety.

"This may seem to some of you a little bit pushy on the part of the Joint Commission," O’Leary said. "But the infectious problems that we are likely to face, even in the near-term future, are really frightening. Human lives are actually at stake."

The 2005 standards reflect the input of an infection control expert panel that was formed last year. The standards focus on the development and implementation of plans to prevent and control infections, with organizations expected to:

  • incorporate an infection control program as a major component of safety and performance improvement programs;
  • perform an ongoing assessment to identify their risks for the acquisition and transmission of infectious agents;
  • effectively use an epidemiological approach, which includes conducting surveillance, collecting data, and interpreting the data;
  • effectively implement infection prevention and control processes;
  • educate and collaborate with leaders across the organization to effectively participate in the design and implementation of the infection control program.

Anticipating a question that was to come up throughout the two-day meeting, O’Leary said at the opening session that hospitals must provide the resources to enact the standards.

"We even add a separate standard on assuring the adequate allocation of resources to support infection control," he emphasized. "We will be surveying that closely. Leaders are also responsible for ensuring adequate training. In the resource-tight times that we live in, education and training are the first to go. We will be looking carefully to ensure those are in place and deployed properly."

Perhaps the most important aspect of the 2005 guidelines is the requirement to conduct a risk assessment at least annually to determine the most important infection control focus areas.

"You need to know what your risks are," said Robert Wise, MD, JCAHO vice president for standards. "Shape a living program that adjusts and adapts over time. The identified risks actually drive the rest of the program. If you identify the wrong target, everything else is going to be wrong in your organization. That’s why we ask for a formal analysis of this at least annually."

Surveillance remains a cornerstone principle, but the 2005 standards add a critical element of intervention, he added. "[We] expect that when issues arise — whether sentinel events or other findings — that something is going to happen," he said. "When our surveyors come on site they are going to be looking for data, action plans, and quantifiable results."

The most controversial new element comes not in the 2005 standards but in the JCAHO’s two-part 2004 patient safety goal to reduce the risk of health care-acquired infections. The first aspect of that is to comply with the new hand hygiene guidelines by the Centers for Disease Control and Prevention (CDC), explained Richard Croteau, MD, JCAHO executive director of strategic initiatives.

The Joint Commission will be looking for health care facilities to adopt all Category I (supported by the most clinical evidence) recommendations in the CDC hand hygiene guidelines, he said.

"As for the Category II recommendations, we will encourage those, but we won’t be surveying and scoring those," he said. "What does that mean in a practical sense? Direct caregivers of high-risk patients can’t wear artificial fingernails. That’s Category I. They should trim their nails to less than a quarter inch, but that’s Category II [and won’t be enforced]."

Managers should consult their local fire marshals and safety regulations regarding the ongoing flap over the use and location of the alcohol-based hand rubs, he added. Noting that hand hygiene compliance usually is no better than 50% in any given study, some conference participants questioned whether the Joint Commission will be looking to spot and punish individual breaches. "We will be looking for patterns," Croteau said, noting that a behavioral change is required that will not occur quickly. It is similar to the Joint Commission’s ongoing effort to reduce medication errors by getting clinicians to stop using medical abbreviations they were taught years ago, he noted.

"What we are looking for is improvement," he said. "Now we are going to be aggressive about [hand hygiene]. Don’t get me wrong. This is serious, and it’s gone on too long."

The second and more controversial part of the infection control 2004 patient safety goal is the Joint Commission’s request to manage as sentinel events all unanticipated patient deaths or permanent loss of function associated with a health care-acquired infection.

"Joint Commission’s position that deaths and disabilities associated with health care-acquired infections are sentinel events — that they require analysis and intervention into cases — has not gone down well with many health care organizations and practitioners," O’Leary told conference attendees. "They argue that the required root-cause analyses are a labor-intensive exercise in futility for a problem that was inherent in the delivery of care. The Joint Commission respectfully disagrees."

Still, when an audience member noted the difficulty in determining whether a patient’s loss of function was "permanent," Croteau said there is no expectation of long-term follow-up.

"At the time of discharge, can you reasonably project a permanent serious injury?" he said. "That is your last, best opportunity to make that observation. We don’t want to get into quibbling about whether something is permanent or not. If we could just strengthen the percentage of reports of these unanticipated deaths, we would have more than enough information that we can learn a lot from."

Ultimately, by learning more about infections and their prevention, the Joint Commission hopes to achieve an ambitious change to an overall culture of safety. Drawing comparisons with aero-space and nuclear agencies, Wise said the goal is a nonpunitive environment driven not so much by standards but by common expectations and a kind of peer pressure to do the right thing. In health care, that could mean some day, when nurses remind physicians to wash their hands, they will kindly thank them for drawing it to their attention, he offered by way of example. Unfortunately, the audience burst into laughter at the thought of that happening in health care reality.

"Believe it or not, that’s what we’re talking about — the type of environment where everybody has the same goals," Wise persisted. "This is a problem that is not going away. In fact, it may get worse. The commitment cannot be just for this year or as a problem of the month."

Indeed, the Joint Commission shows every sign of having locked onto infection control for the foreseeable future.

"The revised standards are officially effective Jan. 1, 2005," O’Leary warned. " I hope no one feels they can relax until that time. Infection control has been an element and focus of our 2003 random unannounced surveys. And we will be looking very close at infection control in our random unannounced infection control surveys next year as well."