A few ICPs will receive a JCAHO surprise party

Infection control targeted for random inspection

The Joint Commission on Accreditation of Healthcare Organizations’ move to target infection control in surprise inspections next year could actually help ICPs in programs that lack administrative support, observers note.

"An organization that has not been supportive of infection control is going to have to really reevaluate that because certainly it is being recognized as an important aspect of patient outcomes," says Susan Kraska, RN, CIC, an ICP at Memorial Hospital of South Bend, IN.

In that regard, struggling ICPs should make their organization aware that infection control is moving front and center on the Joint Commission radar. "Absolutely, I would be cutting out every article and sending e-mails to the front office if that was my situation," she says.

The Joint Commission has deemed infection control a "critical focus area" for 2004 random, unannounced surveys. While only a random 5% sample of accredited organizations are subject to the surprise inspections, infection control also will face scrutiny during regularly scheduled surveys.

"It’s not just unannounced; it’s the full survey as well," says Carol Gilhooley, director of accreditation process improvement at the Joint Commission. "We will look at things like surveillance, prevention and control. We will actually talk to individual patients, employees, and physicians, even contract service workers and volunteers. We want to see a systemwide, integrated process. The organization has to collect data, analyze it, and do something about it — not just leave it out there hanging."

The inspections will be based on the 2004 standards, not the recently drafted 2005 standards. The dizzying pace of activity is part of a series of sweeping standards revisions and survey process improvements known as the Shared Visions-New Pathways initiative. In addition to infection control, staffing and medication management were cited as critical areas for unannounced inspections in 2004.

Random unannounced surveys will end in January 2006 when JCAHO begins conducting all regular accreditation surveys on an unannounced basis. Many ICPs welcome the fact that infection control is now among the most critical aspects of accreditation.

"I am all for this," says Ruth Carrico, RN, MA, CIC, director of infection control at the University of Louisville (KY) Hospital. "The whole idea of a survey is to determine your current level of practice. We all should be practicing as if we were having a survey tomorrow. Tell them the things you do well. This is your opportunity to toot your horn."