Involve key players to address infection control

Hand washing should be across-the-board priority

There is abundant evidence that preventing deadly health care-associated infections is a top priority for the Joint Commission on Accreditation of Healthcare Organizations.

In addition to implementing new infection control standards that will take effect in January 2005, and evaluating compliance with infection control standards during triennial surveys, the Joint Commission has included infection control as a special focus area during random, unannounced surveys.

The Joint Commission also made compliance with the Centers for Disease Control and Preven-tion’s (CDC) recently updated hand hygiene guidelines one of the 2004 patient safety goals.

The new goal for 2004 also requires organizations to manage as sentinel events all health care-associated infections that result in death or major permanent loss of function.

It’s important to note that the only new patient safety goal involves reducing the risk of health care-acquired infections, points out Matthew Rosenblum, chief operations officer for privacy, quality management, and regulatory affairs for New York City-based CPI Directions Inc., a consulting firm that specializes in quality management and compliance.

"The Joint Commission is telling us very clearly that this will be a priority focus area," he says.

"Infection control is right up there with patient safety and medication management," Rosenblum explains.

Preventing infections and resulting deaths

The CDC estimates that 2 million individuals acquire an infection each year while being treated in hospitals for other illnesses or injuries and that 90,000 people die as a result.

He gives these infection control strategies:

Measure hand washing and sentinel events at a minimum.

The data you collect and analyze will depend on which areas your organization has identified as needing improvement.

"Data reporting and measurement is a continuous feedback process, so you should focus on high-risk areas where you may have fallen short in the past," Rosenblum says.

However, because the new safety goal specifically addresses hand washing and sentinel events associated with infection control, these should be across-the-board priorities, he advises. "Our advice is to monitor at least those areas."

Here are some examples of areas to measure:

1. How well are staff practicing hand washing?

2. How well are staff using personal protective equipment?

3. How well are staff implementing specific precaution and isolation procedures?

4. How well are staff implementing cleaning procedures for sterilization?

5. Ensure that staff are well-trained.

Pay close attention to the skill mix of staff, and be certain that they are trained well in infection control techniques, Rosenblum advises.

"It’s one thing to have a great policy and procedure in place. It’s another thing to have skilled and trained staff in place," he says.

Make sure you have adequate equipment needed to implement infection control procedures.

"For example, for sterilizing surgical equipment with autoclaves, you need adequate numbers, and they must be in working condition," Rosenblum says.

Involve key people.

Because the infection control standards cross over to many other standards, you must develop compliance strategies along with key people from affected areas, both when you are implementing policies and procedures and for continuous quality improvement activities, he recommends.

"If a hospital isn’t doing well in infection control, it’s going to impact in a negative way on many other areas," Rosenblum adds.

For example, infection control is a factor during any redesign or construction at your facility, as there may be asbestos and lead issues.

"In that case, you would certainly need somebody from housekeeping or safety involved," he says.

"Or if the infection control issue involves sharps disposal, you will need people responsible for supervising nursing or physician practices," adds Rosenblum.

Similarly, if you identify a lack of adequate training for a process related to infection control, such as proper use of an autoclave, human resources and nursing both would be instrumental, he says.

"This is the one area that really cuts through a lot of other areas, and you need everybody on board," Rosenblum explains.

"Infection control is an area that is everybody’s business," he asserts.

[For more information on the revised infection control standards, contact:

Matthew Rosenblum, Chief Operations Officer, Privacy, Quality Management & Regulatory Affairs, CPI Directions Inc., 10 W. 15th St., Suite 1922, New York, NY 10011. Phone: (212) 675-6367. E-mail: Web:]