Device vise: Joint Commission enforcing OSHA needle mandate

Surveyors at front door, inspectors at the back

Closing the loop on hospitals slow to respond to federal regulation, the Joint Commission on Accreditation of Healthcare Organizations has taken a huge step in speeding the transition from conventional needle devices to those designed to protect health care workers from bloodborne infections. Beginning in April 2002, hospitals that are not complying with the new federal Needlestick Prevention Act face citations by the Joint Commission.

The threat of lost accreditation should stir another flurry of compliance preparations in the nation’s hospitals, as the move essentially deputizes Joint Commission surveyors to enforce regulations by the Occupational Safety and Health Administration (OSHA). While OSHA primarily responds to worker complaints, the Joint Commission conducts regular accreditation surveys as well as unannounced visits.

The collaboration comes as a result of an "educational partnership" formed several years ago between OSHA and the Joint Commission, says Carole Patterson, RN, health care consultant with Joint Commission Resources, a subsidiary of the commission. "It is a horrible thing when people get [needle] stuck," she tells Hospital Infection Control. "We want hospitals to start getting busy and start complying with that law."

Passed by Congress and signed into law Nov. 6, 2000, the needlestick act amends the OSHA bloodborne pathogen standard to require that hospital exposure control plans be reviewed annually to reflect changes in sharps safety technology. Frontline and nonmanagerial workers must be allowed input in evaluating and selecting safety-engineered devices. Infection control professionals must also maintain a sharps injury log that ensures employee privacy and contains, at a minimum, the type and brand of device involved in the incident.

"The immediate result is that we expect to see hospitals and health care organizations involve frontline staff in the review, recommendation, and selection of needleless and sharps replacement devices," Patterson says. "That is what we expect now. Then we would expect to see that the hospital has [implemented devices] or is in the process of doing that."

While some language and compliance examples will be updated in future standard revision, the Joint Commission clarified that current standards give it the power to take the action. The commission requires compliance with "applicable law and regulation" standards in the hospital standards’ "Governance" (GO.2.4) and "Management" (MA.2) chapters. Accredited health care organizations also will find applicable standards in the "Environment of Care" chapter, the "Surveillance, Prevention, and Control of Infection" chapter, the "Care of Patients" chapter, and the "Leadership" chapter, the Joint Commission stated.

The action was announced in the August issue of the Joint Commission’s Sentinel Alert.1 Though given until next April, hospitals should begin preparing because Joint Commission surveyors routinely assess an organization’s familiarity with and use of sentinel event alert information. To some infection control professionals, it was surprising that the Joint Commission addressed the issue as a sentinel alert, which carries its highest sense of urgency in updating requirements to hospitals.

"It’s one thing to say they are going to be looking for compliance; it’s another to make it a sentinel event alert," says Patti Grant, RN, MS, CIC, an ICP at RHD Memorial Medical Center in Dallas. "When they publish a sentinel event, you have some 90 days in an institution to react, respond, and plan. This is a done deal. They have just made the OSHA bloodborne standard mandatory [nationwide]."

While ICPs have been well aware of that Joint Commission/OSHA partnership for years, there is often a distinctly different perception of the two organizations. The accreditation process may be seen as a mutual effort toward health care quality improvement. On the contrary, OSHA is often characterized as a traditional industry regulator that has made an awkward and somewhat uninformed entry into the health care arena. However, ICPs also have noted that if it wasn’t for OSHA, some hospitals would never take sufficient action to protect their workers. For example, Grant praised OSHA for mandating that hepatitis B vaccine be offered to health care workers in the original 1991 bloodborne pathogen standard.

"But what OSHA has just done — and I’m not saying it’s a bad thing — is come in through the back door and made the entire nation that seeks [accreditation] from the Joint Commission accountable to the OSHA federal bloodborne pathogen standard," she says. "I would be complying whether I was an OSHA-bound facility or not. ICPs do the right thing. And the bottom line is we don’t want anybody to get sick. But this is a piece of work — to make it a sentinel event alert when it already has been adopted into the bloodborne pathogen standard."

Indeed, while the inspection/survey experience can always vary with the personalities involved, there looms a larger question now that two forces are dovetailing their requirements.

"The only caveat when you have more than one regulatory body trying to urge people into doing the right thing is that they often come to a crossroads where they disagree about something," says Susan Kraska, RN, CIC, an ICP at Memorial Hospital in South Bend, IN. "If one goes one way and one the other, all of us are left in a lurch. That is something that makes me a little leery."

The move also raises questions about compliance under the various requirements in OSHA federal and state plans, and under individual state laws that have been passed mandating needle safety. ICPs should review their state and local requirements, but Patterson left little doubt that compliance with the OSHA revisions is expected of any accredited hospital.

"Fortunately, we are finding many folks have already replaced [conventional sharps]," she says.

Indeed, many hospitals have implemented needle safety devices, but new products continue to be introduced as regulatory forces pressure the device industry to meet the demands of a changing market. One common misconception, however, is that needlestick injuries will end when protective devices are standard in all hospitals, says Ruth Carrico, RN, MA, CIC, director of infection control at the University of Louisville (KY) Hospital. "I am not convinced that all of the safety items available are truly going to prevent exposure issues," she says. "I know at our facility, we have safety devices all over the place."

Yet injuries still occur either when the device is in use and the needle exposed, or when health care workers fail to activate its protective design, she says. Another problem is that conventional needle devices are still the primary equipment used during basic medical training, leaving hospitals to try to overcome established behavior patterns and preferences. "We work with residents and students from all the disciplines," Carrico says. "It’s tough for them because they have not used [our] devices. Or they may just happen to have a pocket full of another device that they used at another hospital and they really liked. We are going to have to move all of this education back and stop trying to do all of this at the hospital level when people become employees."

In the interim, she expects to work with Joint Commission surveyors as she continues to try to ensure that her hospital is in compliance. "I have never viewed the Joint Commission as being heavy-handed. I have always viewed it as being helpful and trying to encourage us to find ways to practice better. My experience over the years with the Joint Commission is it wants you to follow your own policies. Obviously, our policy should follow what the government is requiring us to do."

In doing so — and with a little less "wiggle room" due to the Joint Commission’s action — ICPs must find the key to compliance without undermining strapped hospital budgets, she says.

"Truly, it is going to be problematic for us because we have to figure out how we incorporate all of these devices safely into our system and in a manner that makes sense for us fiscally," Carrico says. "And, I guess, how we do that is the $64,000 question."


1. Joint Commission on Accreditation of Healthcare Organizations. Sentinel Alert. Preventing needlestick and sharps injuries August 2001; Issue 22. Web site: