JCAHO Update for Infection Control: ICPs have the answers for JCAHO questions

Surveyors particularly curious in making rounds 

Be proactive and get ready for an onslaught of questions — from critical inquiries to the out-of-the-blue variety — if you’re preparing for a visit from the Joint Commission on Accreditation of Healthcare Organizations, advise two infection control professionals who recently went through the process.

"I think the hardest thing to me about the Joint Commission survey is the chaos and the craziness that happens ahead of time," said Karen Anderson, MT(ASCP), an ICP at Marin General Hospital in Greenbrae, CA. "The survey itself is almost a relief when it [arrives]."

When it does, be prepared for all manner of questions, added Rouett Abouzelof, an ICP at LDS Hospital in Salt Lake City.

One of the questions that was asked — and I’m not kidding — is what are you doing to prepare for your replacement? . . . [Meaning] how are you mentoring others?" she said. "You never know what kind of question you might be asked."

Tips from the Troops’ 

The two ICPs detailed their recent survey experiences in a special "Tips from the Troops" session in Phoenix at the annual conference of the Association for Professionals in Infection Control and Epidemiology (APIC).

"Basically, you’re going to have your opening conference, where you introduce yourself, you look at the survey schedule, and make some plans," Abouzelof explained.

The "leadership" interview involves a review of the organization’s structure and goals. "Then [surveyors] start filtering out and doing system tracers and patient tracers," she said.

Grilling the guards 

Patient tracers may involve tracking a patient through an entire clinical care path, from admission to discharge.

For example, Anderson noted that her surveyor took a particular interest in the hospital’s eight-bed correctional treatment center, a locked unit for prisoners from San Quentin. A patient/ prisoner had been admitted to the unit with rule-out tuberculosis, and the surveyor questioned the guards assigned to the unit.

"She wanted to know, what kind of hospital-specific infection control training and safety training they had," Anderson said.

"What would they do in the event of a fire, of an evacuation? What were the codes, things like that. They got questioned a lot, but they are very well-trained," she added.

In contrast, a system tracer may involve review of an entire area such as infection control, environment of care, medication management, and information management.

"They wanted us to go on this facility inspection," Abouzelof noted. "So we went with the surveyors, and we were climbing ladders, looking for dust, seeing if there were barriers [to safety]. You never know what you will be called to do. That’s something that might happen or it might not. It only happened at one of our hospitals, but we were up there on those ladders with them."

With patient tracers, surveyors will wind their way through a variety of clinical departments, she added.

"They are going to be in your clinical areas, your emergency department, acute care floors, intensive care units, or neonatal intensive care units," Abouzelof pointed out.

"They might go down to your X-ray or interventional radiology department and watch them do something. It just depends on what patients they choose, but they will be in the clinical areas," she noted.

The health care facility typically will find out a couple weeks in advance at least part of what surveyors will be reviewing.

"They might base it on something that happened in the past in your hospital, on your previous surveys or ORYX [quality indicator] data you put in, or public data that are submitted. Any of those things could trigger how they want to look at your facility and patients."

2004 patient safety goals 

Of course, the Joint Commission has specific safety goals for infection control this year involving hand hygiene and infection-related sentinel events.

"Those are things they are going to really be focusing on, and that is something that I was concerned about," Abouzelof says.

"They asked us questions about sentinel events. Have you had a sentinel event? How did you identify it? If you haven’t had a sentinel event, how are you looking for them. What do you do when you think you might have found one?

"One thing we do is if there is something that looks like a sentinel event, like a death, then we review it with our infectious disease physicians, and we also have a sentinel event team that reviews these things," she explained.

One of the surveyors wanted to focus heavily on data, reviewing rates and charts, Abouzelof added. "He didn’t ask us a question about hand hygiene," she told APIC attendees. "He wanted to see the data. It was like, Show me the money.’"

In reviewing the data and charts, the surveyor found a large spike in infections and questioned the ICPs accordingly.

"We were able to tell him exactly what type of problem was going on — it was catheter-related — and we could show him directly from the broad picture looking at PICC lines all the way down to this one specific unit where the problem was. He loved it. Within about five minutes, he slapped his hand down on the table and said, "You get an A-plus!"

Anderson had a similar moment of triumph, in part, through her own initiative as a big meeting with several departments was winding down and the surveyor’s focus turned to her department.

With her infectious disease physicians and employee health nurse in attendance, Anderson knew she had the support she needed.

Rather than merely answering the surveyor’s questions, she took the opportunity to highlight the strengths of her program.

"I thought, I’ve worked really hard on this; we’ve done a good job. I’m going to speak up,’" Anderson said. "So I got my nerve up and did that. I talked about the areas that I was proud of."

Front-end documentation important 

One of the keys for both ICPs was documentation on the front end, even though the Joint Commission wants to focus more on process than paperwork.

"I put together a JCAHO compliance manual," Anderson said. "I list the standards and behind each standard, I put my documentation and data that show how I met compliance with that standard. This is not something that surveyors asked to see. They did not want to see a lot of manuals. But for me, it centered my thoughts. I was able to review that and make sure I met all of the standards."

She also gave them surveillance data, infection control committee minutes, and something she called infection control improvements "in a nutshell." Those included a special focus on ventilator-associated pneumonia and an assessment of appropriate antibiotic timing.

"They asked me about my biggest challenges. I told them hand washing was one of them," said Anderson.

"The physician surveyor was in agreement and felt it was going to be very tough for people to do. The infection control survey for me was really a very pleasant experience.

"The surveyors were supportive, educational, [and] they really want to look at the good things that you are doing and support you in that. It was really a good process for me. But a word of warning: You may have a lovefest with the Joint Commission, but it may not be that way with other [regulatory and health department] surveys. You still have to look for the dust bunnies, and you still have to look at refrigerator temperature charts," she explained.