JCAHO Update for Infection Control: Will the Joint Commission’s unannounced surveys catch infection control professionals off-guard?

Concerns about housekeeping, environment of care

Given recent events from emerging infections to the threat of bioterrorism, infection control professionals likely will be prepared for unannounced visits from the Joint Commission on Accreditation of Healthcare Organizations. They can’t afford not to be.

"The job is too important," says Patti Grant, RN, MSN, infection control manager at RHD Memorial Medical Center in Dallas. "We can’t let policies and procedures lapse and say, They’re not coming until next year.’"

However, the Joint Commission’s move to unannounced surveys may undermine the educational aspects of the triennial visit, she laments. "I have always learned things during a Joint Commission visit," she says. "They share ideas. You’re going to be a better institution because they were there. It’s a teaching experience on both sides, and I wonder if that will be lost through the surprise visit."

By the same token, the Joint Commission has drawn fire from both the press and politicians about its collegial inspections and lack of stringent oversight in infection control and other areas. Now JCAHO is making the bold move to begin conducting all regular accreditation surveys on an unannounced basis beginning in January 2006. Unannounced surveys will be pilot tested in volunteer organizations during 2004 and 2005.

The Joint Commission plans to introduce a substantially new accreditation process in 2004, Shared Vision/New Pathways. The discussions of the new approach have frequently included infection control, and as a result, the Joint Commission is considering making the reduction of nosocomial infections a national patient safety goal in 2004.

The transition to unannounced surveys — approved by the Joint Commission board of commissioners at its March 28-29, 2003, meeting — also was a direct outgrowth of the Shared Vision discussions.

"Being ready for a thorough survey at any time is a logical extension of the accredited organization’s commitment to continuous improvement," says Bernard Hengesbaugh, chairman of the Joint Commission board of commissioners.

The Joint Commission will begin pilot testing its new unannounced triennial survey process next year in up to 100 hospitals that have volunteered to be among the first participants.

Four multihospitals systems and alliances — Ascension Health, Tenet Healthcare, Veterans Health Administration, and North Shore-Long Island Jewish Health System — have committed to having a number of their hospitals participate in unannounced triennial surveys in 2004 or 2005.

Also in 2005, JCAHO will continue to conduct voluntary unannounced surveys on a limited basis — opening up the option to all types of accredited organizations, and then transition to a completely unannounced survey program in 2006. During this period, JCAHO will work closely with its various advisory groups, accredited organizations, and other stakeholder groups to gain their input to refine the new accreditation process and smooth the transition to unannounced surveys.

The Joint Commission plans to continue to conduct one-day random, unannounced surveys in an annual 5% sample of the health care organizations it accredits through the end of 2005. After that time, the random unannounced surveys will be discontinued.

The era of surprise triennial surveys will have begun. Essentially, instead of having a scheduled visit in the third year of the triennial process, the organization will only know that the surveyors will show up sometime that year.

Prepare now

Given the Joint Commission’s recent emphasis on infection control, it takes no great leap in logic to expect some emphasis on infection prevention programs when surveyors come knocking. Bring it on, says Grant, who notes that many ICPs have long since gone to a concept of continuous readiness.

"From an infection control standpoint, particularly for any of us who had training and had gone to annual conferences, you learn that your program is an ongoing process," she says. "It is not just paperwork. Unannounced inspections should not impact infection control [negatively]."

Still, there are concerns that housekeeping, which falls under the bailiwick of infection control and environment of care, may not fare well in a surprise inspection, she says. A major part of the problem is that housekeeping departments are chronically understaffed, then geared up prior to a Joint Commission survey. Without the luxury of a scheduled visit, there is some question about how well hospitals will fare in this area, Grant says.

"Things like that will reflect on infection control," she says. "Basic cleanliness is an infection control issue. But this can be both a good and bad thing. You get dinged [with a citation] but hospitals might have to fill the FTEs [positions] they need for housekeeping."

Joint Commission environment of care standards address a broad array of health care standards that may make it vulnerable to surprise inspections. Indeed, a recent report in the JCAHO’s Environment of Care News strongly emphasized maintenance of the hospital environment and equipment as a cardinal aspect of infection control.1

"For the first time in JCAHO’s history, organizations will truly need to be in compliance and prepared for survey at all times," says Bob Bartels, BS, president of Safety Management Services (SMS), a Joint Commission consulting firm in Arlington Heights, IL. "Relative to the environment of care, the effects will be profound. [Our] experience with hospital environment of care programs is that they are rarely in a condition to be surveyed until a month or so prior to the scheduled date. Our analysis of the situation is that hospital safety and facility leaders will have to adjust this routine dramatically to accommodate this new process."

Pitfalls in the area of environment of care

According to Bartels, unannounced surveys may expose potential vulnerabilities in the following environment of care areas:

1. Management Plans: Health care organizations are dynamic places, and change occurs quickly. As major changes occur related to services, geography, and technology, management plans should be updated to reflect these changes. SMS recommends these plans be serviced at least annually to insure they are current.

2. Annual Evaluations: In the past, minor (and sometimes major) lapses in annual evaluations were either overlooked or not detected. Now it will be more critical to have these evaluations done for each of the three years between surveys and done in a timely fashion. SMS strongly suggests that annual evaluations be done within 60 days of year-end.

3. Performance Measures: Many organizations list performance measures in their management plans but are only able to show evaluation of these measures within the last few months prior to survey. Now that organizations will not know when their surveys are coming, it will be more important to maintain a relatively strict schedule of evaluating and reporting on performance measures. SMS recommends not less than semiannual analysis and reporting.

4. Statement of Conditions: The history of many organizations is to not keep these documents current and to frequently miss deadlines. These documents should be reviewed and updated no less than semiannually and preferably quarterly.

5. Interim Life Safety Measures: Keeping records current on ongoing construction activities will help avoid an unnecessary and unwanted deficiency during announced surveys. The second tier of items requiring regular attention includes documentation of fire drills, disaster drills, pre-construction risk assessments, preventive maintenance, hazard surveillance, fire protection equipment testing, and training records.

"While ongoing compliance with all JCAHO environment of care standards is important, the ones identified above will be some of the more critical ones during an unannounced survey," Bartels says.


1. Joint Commission Resources. The facility manager’s role in infection control: Doing your part to reduce organization-required infections. Environment of Care News: The official Joint Commission Environment of Care News Source. May 2003; Vol 6, Issue 5.