JCAHO Update for Infection Control: Joint Commission will roll out 2005 IC standards early

Hospitals inspected this year get consultative’ review

Underscoring the importance of its new infection control standards for 2005, the Joint Commission on Accreditation of Healthcare Organizations has decided to roll out the new requirements on a consultative basis for hospitals being surveyed from July to December of this year.

"They will go into effect in January 2005, but we are doing this because of the feeling of the importance of these standards," says Robert Wise, MD, JCAHO vice president for standards.

"They will be used at the time of review for hospitals being surveyed between July and December [2004]. It is more consultative, but we have a very strong feeling about the importance of these standards. This will be a way to underline that — by rolling them out at that time," he explains.

A sense of compliance

By reviewing the upcoming standards during accreditation surveys, the Joint Commission will get a sense of how well hospitals are going to be able to comply with its new focus on preventing nosocomial infections.

"As we get information during the latter half of this year, we will also have a better understanding of where organizations are having some trouble meeting the standards," Wise says.

"Where they might need to gear up — etc. Are [hospital leaders] aware of what’s going on inside of their programs? Is the [infection control] program working or not working? Do additional resources need to be mustered? [These questions] will certainly be among the critical issues that come up," he notes.

The 2005 standards reflect the input of an infection control expert panel that was formed last year.

The Joint Commission standards focus on the development and implementation of plans to prevent and control infections, with organizations expected to:

  • incorporate an infection control program as a major component of safety and performance improvement programs;
  • perform an ongoing assessment to identify its risks for the acquisition and transmission of infectious agents;
  • effectively use an epidemiological approach, which includes conducting surveillance, collecting data, and interpreting the data;
  • effectively implement infection prevention and control processes;
  • educate and collaborate with leaders across the organization to effectively participate in the design and implementation of the infection control program.

2004 patient safety goals

Meanwhile, the Joint Commission already is looking for compliance with its 2004 patient safety goal to reduce the risk of health care-associated infections (HAIs).

The first aspect of that is to comply with the new hand hygiene guidelines by the Centers for Disease Control and Prevention (CDC).

Rather than the traditional emphasis on soap and sinks, the CDC now recommends the routine use of alcohol-based hand rubs by health care workers. The response has been strong, Wise says.

"We’re hearing [from] a huge amount of hospitals that have now installed alcohol-based hand rubs," he points out. "We haven’t done any formal survey, but just as we talk to people, we are hearing that the majority of organizations are doing it. The issue that has continued to come
up has to do with the place of installation [with regard to fire safety codes]."

Indeed, the National Fire Protection Association requires under its 2000 life safety code — which currently is effective — that the products cannot be mounted in hospital corridors.

There is a movement afoot to amend the code, but in the meantime, the Joint Commission is looking for hospital compliance with the basic CDC recommendation that the alcohol rubs be readily available, Wise says.

Focusing on institutions

Surveyors also are looking for compliance with hand hygiene, but the focus is more on institutional patterns than on an occasional noncompliant worker, he says.

"It is a national patient safety goal, so [surveyors] will be looking at how the organization is complying with those requirements," Wise explains.

"A typical hospital survey might go on for three days. We would attempt to evaluate it from multiple, different angles. It is important to remember that because a single individual doesn’t wash their hands properly does not mean that there is a systemic problem inside the organization. But if you went to multiple floors and you saw people were not [complying], then you would start to worry whether there was, in fact, an effective program," he continues.

The other major component of the 2004 patient safety goal involving infections is an expectation that health care facilities investigate fatal or disabling infections as sentinel events requiring a root-cause analysis. There has been much confusion about this, Wise notes.

"What the typical wrong interpretation of this has been is that for anybody who dies — and in the course of their illness they had an HAI — then we are expecting a root-cause analysis. That is not the correct interpretation," Wise says.

First of all, the Joint Commission views any unanticipated patient death or permanent loss of function as a sentinel event — regardless of the reason.

"That means they came into the hospital, they were not expected to die, and they died," Wise says.

"That is a sentinel event. Those all require a root-cause analysis. If during the root-cause analysis you run across an HAI, one also has to investigate that HAI," he adds.

Caring about what happens to patients

Essentially, the Joint Commission is striving to get ICPs away from an exclusive focus on benchmarking and more involved in the serious outcomes of individual patients.

"In the process of doing a root-cause analysis, you will find that some percentage of those [patients] have HAIs," he says.

"You would then view that as something that had to be looked at and ask the question why did the patient get this HAI? It may have to do with staffing issues or a lack of sterile procedure.

"There is a perception that the only way in which nosocomial infections can be investigated is through statistical methodologies; that you need lots of [infections] before you can [derive] any answers about whether you have an outbreak or something of that nature. Yes, that is something you need to be doing; but in certain cases, you also need to looking at the specific incident," Wise stresses.