Draft standards detail policy demands for ICPs

The nuts and bolts of a more prescriptive approach

The Oakbrook Terrace-based Joint Commission on Accreditation of Healthcare Organizations’ proposed infection control standards for 2005 include a more prescriptive approach that already is proving controversial.

Many of the requirements are detailed in the new standard IC.2.10, which outlines expectations for documentation and written policies. According to the Joint Commission draft, the written plan should be "a succinct, useful document, formulated beforehand, that identifies needs, lists strategies to meet those needs, and sets goals and objectives. The format of the plan may include narratives, policies and procedures, protocols, practice guidelines, clinical paths, care maps, or a combination of these."

For the complete infection control draft standards for 2005, go to http://www.jcaho.org/. Select "Accredited Organizations." Under "What’s New for Accredited Organizations," select "Hospitals," and then select "2005 Proposed Standards."

The standard rationale and elements of performance include the following:

Standard IC.2.10

The organization has an organizationwide, written infection prevention and control plan.


A written plan identifies priorities, focuses the activities of the program, and structures evaluation of the efficacy of the program based on identified risks and risk reduction strategies.

Elements of Performance for IC.2.10

1. The organization’s infection prevention and control plan is in writing and is easily accessible to licensed independent practitioners (LIPs), staff, students/trainees, and volunteers.

2. The organization’s infection prevention and control plan includes:

A. A description of the responsibilities of each department/service/program/unit that has a part in the infection prevention and control program

B. A description of the scope of the surveillance activities, which include:

• the focus of surveillance with a description of the rationale for the focus

• the methods of surveillance

• tracking incidence and prevalence rates of infections

• investigations of outbreaks of infectious diseases within the organization

• role (if any) in community/public health surveillance

C. Individuals (by position or name) responsible for approving actions to prevent or control the transmission of infections

D. Systems for reporting information:

• within the organization to the appropriate staff

• to federal, state, and local public health authorities in accordance with law and regulation

E. Activities for LIPs’, patient staff’s, students’ /trainees’, and volunteers’ health including processes for:

• the appropriate use of standard precautions and other applicable precautions to reduce the transmission of infectious agents be-tween and among LIPs, patients, staff, visitors, student/trainees, and volunteers

• an organizationwide program to address hand hygiene among LIPs, staff, students/ trainees and volunteers.

• screening for exposures and/or immunity to infectious diseases based on demographics of the population served and/or the geographic location of the organization

• minimizing risks associated with medical devices

• immunization programs (if offered)

• LIPs, staff, student/trainees, and volunteers diagnosed with an infectious disease that may put the population they serve at risk

• LIPs, staff, student/trainees, and volunteers who have been occupationally exposed

• the availability and use of personal protective equipment and/or clothing

• strategies for reducing risks for infections related to the use of devices and procedures required for patient care

F. Systems for communicating with LIPs, staff, students/trainees, and volunteers about infection prevention and control issues

G. Processes for equipment management including:

• appropriate cleaning, disinfection, and/or sterilization of supplies and equipment

• the reuse of equipment designated by the manufacturer as disposable, consistent with regulatory and professional standards

• storage

3. Infection prevention and control policies, procedures, and activities are based on guidelines and successful practices.