JCAHO strengthens infection standards

Renewed interest in HAIs spurs agency to action

The Joint Commission on Accreditation of Healthcare Organizations has approved revised standards to help prevent the occurrence of deadly health care-associated infections (HAIs). The standards retain many of the concepts embodied in existing standards but sharpen and raise expectations of organizational leadership and of the infection control program itself. The requirements for ambulatory care, behavioral health care, home care, hospital, laboratory, and long-term care organizations will take effect January 2005.

"There has been, over the last number of years, renewed interest in the amount of HAIs in the country," notes Robert Wise, MD, vice president of the division of standards at the Joint Commission. "The CDC [Centers for Disease Control and Prevention] continues to publish data that show somewhere between 2 million and 4 million health care-associated infections exist, with 90,000 deaths per year associated with those HAIs."

A CDC guideline published in October 2002 for hand hygiene in the health care setting — the culmination of 20 years of data — indicates that one of the main ways to stop cross-infection is, in fact, hand washing. "Yet health care professionals are doing an abysmal job of washing their hands," Wise asserts. "And we have more and more people in hospitals who are susceptible, immunocompromised, and at greater mortality and morbidity risk."

For years, the health care profession had recognized HAIs were too high but had argued about how many were preventable, he points out. "But now we have identified a method that can clearly reduce them — just by washing our hands. So if even the basic things are not being done, we realized we needed to look at overall strategies."

An extensive dialogue

This laid the groundwork for a group of experts to have an extensive dialogue on the topic, Wise says. The group was formed in early 2003. "There are two ways we vet standards," he explains. "With something as technical as this, we go out and find the people who are experts in the area [infection-control practitioners, hospital epidemiologists, physicians, nurses, risk managers, and other health care professionals] such as John Boyce, one of the main authors of the CDC guideline for hand hygiene, as well as health care organizations and major stakeholders. Then, it will be put out [to all accredited organizations] for field review across the country."

The field review will include two new issues — emerging antimicrobial resistance and the management of epidemics and emerging pathogens — that have been identified since the group began its work. For the Joint Commission, prevention represents one of the major safety initiatives that a health care organization can undertake. The revised standards focus on the development and implementation of plans to prevent and control infections, with organizations expected to take these steps:

  • Incorporate an infection control program as a major component of safety and performance improvement programs.
  • Perform an ongoing assessment to identify 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.

Another key aspect of the revised standards is an increase in the pressure placed upon top-level management in health care organizations. "This is a pretty important point," Wise points out. "One of the issues that kept coming up concerning the problems with infection control programs is that they are too low down in the organization. The practitioners who run them don’t reach the people who are high enough to help; they have trouble getting resources and training. So what you get is a nice program on paper, but [one that is difficult] to implement. You need a leadership voice; this is not a program that sits in a single unit or department — it only works if it is organizationwide."

Taking a realistic approach

The Joint Commission is expecting a lot from health care organizations, but it also is being realistic when it comes to those expectations. "There is no organization today that has the amount of money needed to handle every infection problem, and we appreciate that," Wise says. "There is, however, an expectation that each organization understands where its greatest vulnerabilities are. We expect a thoughtful plan to be put together that indicates it knows exactly where its greatest threats exist. It could be surveillance data, not being able to get the proper staff, or training problems; whatever they are, they need to be addressed," he explains.

Essentially, the process improvement must include an understanding of what the goals are, why the facility chose those goals, a description of the problems within the organization, an attempt to fix those problems, and if they are not fixed, an explanation as to why they were not fixed, Wise says. The revised infection controls standards will not be a part of the scored survey until January 2005, he notes. "But because they are so important, we will release them in July 2004," Wise stresses. "If an organization is surveyed in the last half of the year, there will be consultations on these standards, indicating how they might have been scored and what problems would have been cited."

The Joint Commission also has made the CDC’s recently updated hand-washing guidelines a 2004 National Patient Safety Goal for all accredited organizations. Further, the Joint Commission has advised accredited organizations that HAIs resulting in death or serious injury also should be voluntarily reported to the Sentinel Event database.

For more information, contact:

Robert Wise, MD, Vice President, Division of Standards, Joint Commission on Accreditation of Healthcare Organizations, Oakbrook Terrace, IL. Phone: (630) 792-5890. Web: www.jcaho.org.