JCAHO Update for Infection Control

Real-world examples of JCAHO questions

How do you review line-related infections?

The following questions were among those asked during two recent surveys by the Joint Commission.

The questions do not represent any kind of official survey, but were simply noted anecdotally by two infection control professionals as the questions were asked to them and other staff members. 

Surveyors asked these questions during individual patient tracer inspections and system tracer inspections of the infection control department:

• Do you do 100% surveillance, or do you focus on specific populations?

• What are some of the challenges you have had to deal with in the past year?

• If a sign "construction" pops up, how do you address this?

• How does employee health fit into this picture?

• Have you had any outbreaks among the employees?

• What have you done regarding smallpox vaccination in response to bioterrorism threat?

• How does pharmacy interact with infection control?

• Do you do random monitoring to make sure the pharmacy processes are working the way they should?

• What have you done about fingernails?

• As a group have you identified how an infectious problem might have led to a patient’s death?

• Has behavioral health had any outbreaks?

• Do you keep data on infections in behavioral health?

• Has the lab converted to needleless devices?

• How is the OR doing on converting to needleless systems?

• Has respiratory therapy made any changes to prevent nosocomial infections?

• How does engineering fit into the infection control process?

• Does engineering participate in the infection control committee?

• How does bioengineering participate in the infection control process?

• Where do dialysis water testing results go?

• What kinds of data do you routinely collect?

• How do you collect your data?

• How do you use your data?

• How do you review line-related infections?

• What is an example of a success that you have had in the past 12 months?

• Do you attend environment-of-care meetings?

• What data are you collecting relative to the national patient safety goals?

• Have you already collected evidence on this topic?

• How are the doctors involved in the infection control process?

• How many nosocomial infections do you see in a year?

• What is the average cost of a nosocomial infection in this hospital?

• Do you track prophylactic antibiotic use for each surgeon?

• Do you track endoscopic infections, cleaning of scopes, outbreaks, etc.?

• How do you know that techs who clean the scopes are doing it correctly?

• Do you keep records of the infection rate for gastric by-pass surgeries?

• How do you do outpatient surveillance on infections?

• How are total joint infections identified and tracked?

• How does the director of central processing communicate with infection control?

• If there is a failure of the sterilizer (biological indicator), how is this communicated and what do you do?

• Have there been any infection control concerns with the rehab swimming pool?

• Since you have three emergency departments (in three affiliated hospitals), what is the same and what is different in preparing for bioterrorism?

• How do you work with the community and health department?

• Do all of your hospitals use the same protocols for infection control, and what about the outpatient clinics?

• Several specific questions were asked about hand hygiene evaluations, interventions, and explanations of rates

• How often do you educate employees about infection control issues?

• In response to a specific cluster of infections, how did you respond, who was involved in the decision-making process, what guidelines did you use, how was nursing involved, and what is the current status and follow-up for these infections?

• What are you doing to prevent ventilator-associated pneumonias, and what specific evidence-based practices are you using?

• What is your community pneumonia protocol?

• Do you have a SARS plan? If there was a patient with signs and symptoms of a respiratory infectious disease, who initiates the plan and who calls the infection control staff or infectious disease physician?

• Give me an example of how you select products for clinical use that might have infection control implications.

• Show me your construction risk assessment and how you monitor the site. How do the construction or engineers know what to do to prevent possible construction-related infections?

• Tell me about infections in total joint replacements. What are your rates and how does this compare with other hospitals (locally or nationally)?

• Do you use antimicrobial-coated IV catheters? Why or why not?