JCAHO Update for Infection Control

JCAHO cites collaboration, adequate resources for 2005

New standards effective Jan. 1, 2005

New infection control standards by the Joint Com-mission describe a widely supported and collaborative program that represents one of a hospital’s top priorities. Highlights of the 2005 standards, which are effective next Jan. 1, include this statement in the overview: "Health care-associated infections (HAIs) represent one of the major safety initiatives an organization can undertake, making the effective evaluation and possible redesign of existing infection prevention and control programs (IC program) a priority. Key program support standards include:

Standard IC.8.10

Representatives from relevant components/functions within the hospital collaborate to implement the infection control program.

Rationale

The successful creation of an organizationwide IC program requires collaboration with all relevant components/functions. This collaboration is vital to the successful gathering and interpretation of data, design of interventions, and effective implementation of interventions. Managers within the hospital who have the power to implement plans and make decisions about interventions related to infection prevention and control participate in the IC program. While a formal committee consisting of leadership and other components is not required as evidence of this collaboration, the hospital may want to consider this option.

Elements of Performance for IC.8.10

1. Hospital leaders including medical staff, licensed independent practitioners, and other direct and indirect patient care staff (including, when applicable, pharmacy, laboratory, administration, central supply/sterilization services, housekeeping, building maintenance/engineering, and food services) collaborate on an ongoing basis with the qualified individual(s) managing the infection control program.

2. Those representatives participate in these activities:

• Development of strategies for each component’s/function’s role in the IC program.

• Assessment of the adequacy of the human, information, physical, and financial resources allocated to support infection prevention and control activities.

• Assessment of the overall failure or success of key processes for preventing and controlling infection.

• The review and revision of the IC program as warranted to improve outcomes.

Standard IC.9.10

Hospital leaders allocate adequate resources for the infection control program.

Rationale

Adequate resources are needed to effectively plan and successfully implement a program of this scope.

Elements of Performance for IC.9.10

1. Leaders review on an ongoing basis (but no less frequently than annually) the effectiveness of the hospital’s infection prevention and control activities and report their findings to the integrated patient safety program.

2. Adequate systems to access information are provided to support infection prevention and control activities.

3. When applicable, adequate laboratory support is provided to support infection prevention and control activities.

4. Adequate equipment and supplies are provided to support infection prevention and control activities.