Amid controversy, JCAHO raising profile of infection control, seeking ICP input

Serious, deadly infections will have to be reported to JCAHO

Like some unusual alignment of the planets, the new year begins with a convergence of major issues regarding the nation’s infection control programs and their most critical professional partner: the Joint Commission on Accreditation of Healthcare Organizations. The result could be landmark changes for ICPs, as the Joint Commission is raising the profile of infection control as part of its continuing emphasis on patient safety.

The Centers for Disease Control and Prevention (CDC), at least in public discussions of the issue, has downplayed its longstanding approach that infection rates within a given benchmark range were more or less acceptable. Instead, the CDC — now under the direction of veteran health care epidemiologist Julie Gerberding, MD — emphasizes the importance of striving for zero infections.¹ The Joint Commission is in the process of making a similar paradigm shift, particularly in its view of serious hospital-acquired infections.

"We have specifically begun discussing exactly that issue," says Paul Schyve, MD, Joint Commission senior vice president. "If a patient dies in a hospital or has a permanent disability as a result of a nosocomial infection, the hospital really should think about that as a sentinel event and treat it and evaluate as such. When the outcome is that serious, it is not the same as saying let’s add these [infections] up and look for trends and patterns. It is, in fact, a sentinel event. Everybody understands that there are nosocomial infections that occur, [but] it seems that people haven’t perhaps thought of them in quite those terms. We will be urging people to think of it that way."

As part of that emphasis, the Joint Commission plans to advise accredited organizations in the near future that nosocomial infections resulting in death or serious injury also should be reported to the Joint Commission’s database.

New IC task force to hold first meeting

That directive, no doubt, will be relayed to leaders in the field when the Joint Commission convenes the first meeting of a special task force on infection control in late January or early February. The Joint Commission decided to form the panel after ICPs protested a proposal to consolidate and reduce the number of infection control standards in 2004, when the commission plans to implement its ambitious Shared Vision/New Pathways accreditation program. (See Hospital Infection Control, December 2002, under archives at www.HIConline.com.)

In of itself, the "shared vision" program represents one of the most comprehensive revisions of the accreditation process the Joint Commission has ever attempted. The changes are nothing less than "revolutionary," says Dennis O’Leary, MD, Joint Commission chairman. "The net effect of these changes will be to substantially increase the relevancy of the accreditation process to health care organizations and to direct even greater attention to improving patient safety and health care quality," he says. "We [have] operated, in part, out of a black box. I mean, the organizations knew what the standards were. They knew what the intent was, but they weren’t sure exactly what the surveyors were looking at and how they were being scored for their compliance on the standards. Now, it’s all transparent."

The infection control aspect of the new approach will be added after the considerations of the newly formed task force, a panel of some 20 members that will include ICPs, epidemiologists, other clinicians, and administrators, Schyve says. But what began as a flap over standards has now opened up into a much wider discussion about infection control and what many believe is its key for survival — accreditation requirements by the Joint Commission.

One of the reasons for the expanding agenda is that even as it was pursuing sweeping changes under its 2004 shared vision initiative, the Joint Commission was stung by a critical article in the Chicago Tribune. That recent article, on the heels of a strident and somewhat inaccurate investigation of nosocomial infections by the Tribune earlier last year, charged the Joint Commission with "shielding" hospitals with infection control problems.² (See HIC, September 2002, under archives at HIConline.com.) "Have we looked at the article and decided we need to communicate better to other audiences what the issues are and how we are trying to address them?" Schyve asks. "The answer is yes."

The Joint Commission already has come out strongly on patient safety issues, implementing numerous initiatives that include advising patients to speak up about the quality of their care. Now it appears infection control is moving into the spotlight, with a special session added to an annual surveyor-training program being held this month. "This is before the infection control panel has even met and has nothing to do with Shared Vision/New Pathways," he says. "Obviously, there is an issue around infection control, [so we decided to] have a refresher course on good infection control and how best to survey the current standards."

While acknowledging that there were problems, Thomas R. Russell, MD, FACS, executive director of the American College of Surgeons in Chicago, commended the Joint Commissions ongoing efforts to improve the situation. "Unlike many other industries that do nothing to undertake reform efforts until public scandal makes such an activity a necessity, the Joint Commission has acknowledged that its accreditation system does have flaws, and it has publicly committed itself to numerous activities that it anticipates will result in true reform," Russell said in a statement issued in response to the Tribune article. "It should be pointed out that the Joint Commission faces a great challenge in surveying hospitals because many hospitals do not have good reporting systems, so many times the data hospitals provide are inadequate. In addition, it must be said that many hospitals simply try to pass the accreditation process and are not using the exercise as a positive and truly constructive way of achieving quality improvement."

Still, in issuing its own statement of response to the Tribune, the Joint Commission sounded somewhat defensive, pointing to the upcoming infection control task force without mentioning it was formed, in part, due to pressure from ICPs.

"Resource constraints and staffing shortages create patient safety vulnerabilities and force even conscientious health care professionals, in some circumstances, to forego basic necessities such as hand washing in order to meet urgent patient care needs. It is problems such as these that set the stage for the types of serious and deplorable outbreaks of nosocomial [hospital-acquired] infections portrayed in the Tribune article. The Joint Commission has long worked with experts in multiple fields — specifically including infection control — to set and maintain state-of-the-art standards," the organization stated. "Indeed, the Joint Commission is presently appointing a new expert panel on infection control which will first convene in January 2003."

Thus, with the Joint Commission already at midstream in its Shared Vision changes, ICPs protesting standards changes, and the Tribune giving them a black eye in the press, the organization decided to put everything on the table when the infection control panel convenes.

"What we are charging them to do is essentially look at the whole issue," Schyve says. "What is the current state of knowledge and available technology? Do the current standards focus on critical, emerging issues? How do infection control issues differ across different kinds of organizations — hospitals, home care, ambulatory, and so on. We are also going to be asking the expert panel, What would be the best techniques to use to survey an organization [for infection control compliance]?’"

For example, the Shared Vision program will use so-called "tracer" methods to track the course of a single patient through his or her care within an organization. "The question that arises is does that technology work for evaluating infection control or will we have to make some adaptations with that?" Schyve says.

New ICP staffing ratio will be discussed

Another hot topic of discussion that will be put to the panel is infection control department staffing. The guideline for staffing infection control programs traditionally has been one ICP for every 250 acute care beds, but a recently published study indicates the ratio should be approximately one ICP per 100 licensed beds under current conditions in health care.³

"I think this study is obviously something we would put in front of the task force and see if [it has] specific recommendations for any kind of changes in the approach that we should take," Schyve says. The Joint Commission has emphasized in its standards that infection control programs should be adequately staffed, but has never required a specific ratio or formula, he adds. "One of the issues that we always have to take into account is the differences in organizations and patient mix," he says. "That’s one reason why we have concluded that hard-and-fast staffing ratios — say for nurses — are not the best way to approach staffing effectiveness."

Staffing, in general, increasingly is being linked to the patient safety issue and could become an issue for infection control departments as well. The Joint Commission — in its response to the Tribune — cited the need for public policy-makers to provide "adequate resources to support safe and effective health care delivery."

The Joint Commission does not have a firm timeline on when the infection control committee will report its findings or recommendations, but in the interim, the organization will move ahead with is Shared Vision changes. "Because of the major revisions in the Shared Vision/New Pathways, we want to have those published and in the field by about mid-2003, so [health care organizations] have plenty of time to get used to them," he says. Any revisions of infection control issues based on the task force discussion will be added at a later date. In addition to infection control, two other areas — medical staff standards and information management — also are under revision with an eye toward the new standards in 2004.

(Editor’s note: To help ICPs understand and comply with ongoing changes by the Joint Commission, Hospital Infection Control will begin publishing a free new quarterly supplement. Look for the first issue of JCAHO Update for Infection Control in your February 2003 issue of HIC.)

References

1. Gerberding JL. Hospital-onset infections: A patient safety issue. Ann Intern Med 2002; 137:665-670.

2. Berens MJ, Japsen B. Patients suffer as agency shields troubled hospitals: Clean bills of health are awarded despite deaths, infection outbreaks. Chicago Tribune, Nov. 10, 2002.

3. O’Boyle C, Jackson M, Henly SJ. Staffing requirements for infection control programs in U.S. health care facilities: Delphi project. Am J Infect Control October 2002; 30.