New standards, surprise inspections demonstrate JCAHO’s emphasis on IC

2005 draft standards return to prescriptive’ approach

The Joint Commission on Accreditation of Healthcare Organizations has raised the ante again on infection control professionals, drafting prescriptive new standards for 2005 and putting the field at the top of the list for surprise inspections next year.

"With the whole new accreditation process —- Shared Visions/New Pathways — we are trying to focus on the most important issues related to quality and safety of care," says Carol Gilhooley, director of accreditation process improvement at the Joint Commission. "Infection control has risen to the forefront."

The Joint Commission has targeted infection control as a "critical focus area" for 2004 random, unannounced surveys. The latest developments continue its unprecedented focus on infection control, including formation of a special committee of epidemiologists last year after ICPs protested a proposal to consolidate and reduce the number of infection control standards in 2004. (See Hospital Infection Control, December 2002, under archives at

The 2004 standards now are largely unchanged from this year, but the standards proposed for 2005 are much more specific regarding program description and documentation.

The requirements include a written plan "that identifies priorities, focuses the activities, and evaluates the efficacy of the program based on identified risks and risk-reduction strategies."

In issuing the proposed 2005 standards, the Joint Commission cited Centers for Disease Control and Prevention (CDC) estimates that there are approximately 90,000 nosocomial infection-related deaths in the United States each year. "The importance of infection prevention and control to the safety, as well as the quality, of patient care suggested the need for a complete review of the Joint Commission’s current infection control standards," Dennis O’Leary, MD, Joint Commission president said in a statement.

"In many instances, the standards would retain their current focus but become more prescriptive in nature. The overall intent of these standards revisions is to place greater emphasis on infection control problem identification and active intervention," he added.

With input from the expert panel, the Joint Commission identified the following six critical infection control areas:

• staffing and personnel issues;

• adherence to national guidelines;

• employee health;

• data collection and analysis;

• the environment of care;

• infection control program evaluation.

Too much busy work?

The new prescriptive approach and focus on documentation has not been well received by some ICPs.

"Every minute spent writing policies and procedures and disseminating information on written paper is that much time taken away from real work, [such as] surveillance and education," says Helen Litvack, RN, MSN, CIC, nurse epidemiologist at Vassar Brothers Medical Center in Poughkeepsie, NY. "To sit and write all of that stuff is a full-time job and does not ensure quality. I mean, every day we are dealing with a new disease — real problems that show up in the emergency room. It’s ridiculous."

But others in the field note that ICPs can’t have it both ways, protesting when the Joint Commission standards appear either to be shrinking or expanding. Joint Commission requirements, as many have long observed, are probably the only reason infection control has survived as a profession.

"Let’s face it, [ICPs] got real concerned when the infection control standards started getting too thin and too vague," says Ona Montgomery, RN, MSHA, CIC, infection control coordinator at the Department of Veterans Affairs Medical Center in Amarillo, TX. "Infection control programs didn’t get much support until the Joint Commission started requiring them in their standards."

That said, it has always been difficult to measure and demonstrate an infection prevention’s program efficacy, she concedes.

"[The standards] are more prescriptive, but I like the fact that they have specifically required a written, prioritized program plan," Montgomery says. "Over the years, it has sort of been assumed that’s what you would have, but it really hasn’t been written in the standards in a long time."

One of the recurrent areas of emphasis is that the infection control program must be collaborative, applying to "all programs, services, and settings" within a hospital.

"What we are trying to do is to get people to look at systems and processes in an integrated fashion," Gilhooley explains. "

So when they are looking at infection control, they are looking at organizationwide communication, staffing, and all of the things that impact infection control. Not just a policy or procedure that they have in a book," she points out.

The proposed standards emphasize that the nature of infection control places responsibility for prevention activities among "all departments and individuals" in an institution.

"People tend to think that the infection control program belongs to them, and if there is a problem it is their fault or responsibility," says Ruth Carrico, RN, MA, CIC, director of infection control at the University of Louisville (KY) Hospital. "To me, the way the Joint Commission is leaning is continuing to stress the infection control program goes across all hospital functions. It takes the I’ out of infection."

The Joint Commission proposed standards also emphasize that the written plan has to be readily accessible to staff, which could be a key step in broadening infection control responsibilities hospitalwide, Montgomery notes.

"[If] the infection control responsibilities reside throughout the organization, then everybody should be able to see how they fit in," she said. "That is something that we have probably not done well in all of our programs. I don’t know that just making it accessible to staff does it, but I think the intent is that more of the rank and file know where they fit into the infection control program."

On the other hand, Montgomery questions why so many elements of employee health fall under the responsibility of infection control in the proposed standards.

"I am struck by how much employee health information and content is in this standard, and yet there is no occupational health standard per se within the Joint Commission system," she adds. "Although they talk repeatedly about the elements of employee health that impact on infection prevention, they don’t address the infrastructure for employee health."

In addition, the standards only generally refer to the need for "effective" infection control staffing, leaving institutions to be the arbiters of that effectiveness.

"I was hoping there would be a little bit more content on how to assess appropriate staffing," Montgomery says. "We know that there can’t be an easy formula for determining staffing ratios, but you might expect somewhere it would specify that there is evidence that leadership had evaluated the appropriateness of staffing."

Given the use of more descriptive statements in the draft standards, it is somewhat surprising that the Joint Commission did not trumpet infection control as a patient safety program, she adds.

There are references to continuous quality improvement approaches but few nods to the more recent nomenclature of the patient safety movement.

"In a lot of Joint Commission publications, they are talking about that critical link between infection control and patient safety," Montgomery explains. "I didn’t see that patient safety wording come out in the standards very strongly. I’m really surprised there wasn’t some additional wording in the standards that emphasized that link."

Also conspicuous in its absence — not that anyone is necessarily complaining — is mention of the Joint Commission’s request for reports of fatal or debilitating nosocomial infections.

The Joint Commission previously issued a Sentinel Event Alert instructing ICPs to "manage as sentinel events all identified cases of death and major permanent loss of function attributed to a nosocomial infection [i.e., except for the infection, the patient would probably not have died or suffered loss of function]." The move was prompted in part by press criticism that many nosocomial-related deaths occur, yet few reports are in the Joint Commission database.

"Nosocomial infections have been underreported to us," Gilhooley says. "Maybe, with this [recent] emphasis, people might start to make the connection that nosocomial infections that lead to death or serious impairment are sentinel events and, hopefully, increase reporting."

However, the request for data has been controversial, and some ICPs warned early on that the epidemiologic soundness of the request was questionable.

"I think of all things that is the most difficult to assess — whether a nosocomial infection was the proximal cause of death or permanent disability," Montgomery adds. "[But] it really surprised me that there is no real mention in these standards of infection-related sentinel events."

Though the comment period has closed, the guidelines still are subject to revision. The Joint Commission’s expert infection control panel is slated to meet to discuss them in mid-August.