JCAHO Update for Infection Control

JCAHO moving to change historical hand hygiene failures

Surveyors from the Joint Commission on Accreditation of Healthcare Organizations are putting an unprecedented emphasis on infection control’s most frustrating problem — hand washing.

Historical arguments and time-honored excuses for the typical 40% compliance range are out. The Joint Commission is now looking — by direct observation — at hand hygiene as a cardinal principle of infection control. Period. One of the prime factors in the change is that the Joint Commission continues to make hand hygiene a national patient safety goal.

"There is no partial compliance with national patient safety goals," said Tammy Lundstrom, MD, JD, epidemiologist at Detroit Medical Center. "You either do it or you don’t."

Moreover, the new no-nonsense attitude dovetails the tone increasingly taken by infection control professionals, who say the health care system has been too passive for too long on this critical patient safety issue.

Of note was the "no more excuses" message delivered by one of the top hand washing researchers in the nation at the annual meeting of the Association for Professionals in Infection Control and Epidemiology (APIC) held recently in Baltimore.

"We repeatedly document the fact that hand hygiene compliance rates are abysmal, particularly in the highest risk areas, such as the ICU," said Elaine Larson, RN, PhD, CIC, professor of pharmaceutical and therapeutic research at Columbia University School of Nursing in New York City. "There is an actual significant inverse correlation between the risk and the importance of hand hygiene and the extent to which people do it. Why do we continue to do observational studies to identify this problem and do so little about it?" she asked.

Scalded by increasing bad press about hospital infections, the Joint Commission has focused heavily on infection control in the last few years. For example, to meet the hand hygiene patient safety goal, JCAHO requires compliance with the evidence-based recommendations in the hand hygiene guidelines issued by the Centers for Disease Control and Prevention (CDC) in 2002.1

"Staff should know what is expected of them with regard to hand hygiene and should practice it consistently," the JCAHO patient safety goal states. "Implementation of all CDC guidelines with Category IA, IB, or IC evidence is required." (See recommendations.)

By taking this action, the Joint Commission essentially codified the voluntary CDC guidelines, setting a standard for medical care that could echo in the courtroom.

"The Joint Commission has taken it to a whole new level by [saying] you must do CDC guidelines," said Lundstrom, a physician with a law degree. "That really ends up setting a national standard, which becomes a legal standard. It’s difficult to defend not implementing CDC IA guidelines if you should have a lawsuit related to a nosocomial infection," she added.

"The [JCAHO] scoring has changed for the hand hygiene requirement," Lundstrom continued. "The JCAHO surveyors going out on [patient] tracers are observing each and every heath care worker as they perform tasks to make sure that they adequately wash their hands.

"They used to say a minimum of 90% compliance was expected, but now they are scoring by observation. It is a kind of three strikes and you are out’ rule," she noted. "If they find three instances in different health care workers not washing their hands . . . one occurrence equals one observation of noncompliance. Three strikes and you are out," Lundstrom added.

In keeping with the CDC guidelines — which heavily emphasize the use of alcohol-based hand rubs — the Joint Commission expects hospitals to involve health care workers in the selection of hand hygiene agents.

The requirement is similar to the Occupational Safety and Health Administration’s mandate that frontline workers be involved in the selection of needle safety devices.

Some things to look at in hand hygiene agents are the feel, fragrance, and skin tolerance, Lundstrom told attendees.

ICPs should investigate any interactions between the agents, hand lotions, and gloves. Evaluate various dispensing technologies and make sure that people are not topping off partially empty dispensers, she added. "CDC also puts performance indicators at the end of their document, and JCAHO will be looking for these when they come in," Lundstrom said. "At least, they did in our three facilities surveyed to date."

The performance measures include a recommendation to periodically monitor and record adherence as the number of hand hygiene episodes performed by personnel. Moreover, they include providing feedback to personnel regarding their performance.

Rather than risk a Hawthorne effect by showing up in person, Lundstrom has developed a system of unannounced staff observers.

"What we do is we have a secret observer every week," she said, referring to a neonatal intensive care unit.

"That observer is one of the staff who commonly or always works on that unit. We pick out one staff [member] from the duty roster and make them the observer of the week.

"We ask them not to tell . . . then we go and just do validation observations. I feel more comfortable about it than having me go up there, because if the doctors see me coming, they wash their hands," Lundstrom explained.

Another CDC hand hygiene performance measure is to monitor the volume of alcohol-based hand rub used per 1,000-patient days.

"We have never found this helpful; there are too many storage places to [keep track of]," she said, adding that tracking is further complicated by the fact that any staff member can refill an empty dispenser.

"So it is very hard for us to keep track on a unit-by-unit basis. In any case, we were doing it [as best we can], and JCAHO found it acceptable," Lundstrom pointed out.

In addition, posters, e-mail messages, tipsheets, and even computer screen savers, are used to reinforce the message that hand hygiene prevents patient infections, she said.

The Joint Commission has raised the bar, and a few eyebrows went up with it when word spread that full compliance was the new expectation. Part of the reason for that is that concept of partial compliance with hand hygiene has become ingrained in the health care system.

In an era of patient safety, the accepted failure rate is shocking when it is put down in cold hard print. Consider this excerpt from a recently published article in The Lancet: "It is no longer acceptable for hospitals with substandard adherence to these basic interventions to excuse their performance as being no worse than the dismal results in published reports. Most institutions still tolerate defect or failure rates in hand hygiene of 40% of more — levels that would be considered shocking in any other industry."2

No excuses/no tolerance

Similarly, it’s time to end the excuses, such as one group of health care workers implying the problem lies in another group. Likewise, the old argument that health care workers are too busy to disinfect their hands between patients is a nonstarter.

"We have all kinds of reasons why this is OK," Larson told attendees. "I hear this all of the time. We expect the public to understand how important our work is. We have emergency after emergency and it’s so important we have legitimate excuses for failing to perform routine tasks."

But patients and the lay press — who are becoming more aware of the problem of hospital-associated infections — find the old explanations rather astonishing.

"People look at you like you were speaking another language. It does not make sense," Larson added. "We would never tolerate a pilot [saying he or she was] too distracted, too tired . . . to assure that all systems are functioning before a flight."

Yet another observational research paper documenting failed compliance is not what is needed, she added.

"Those of us who are doing research sometimes distance ourselves by merely saying, Ok. I published it. It’s out there. It’s up to you.’ That’s not acceptable. We cannot beg away from our own responsibility," Larson explained.

That responsibility extends beyond caregivers to top administration, which is sensitive to the issue of Joint Commission accreditation problems.

"Stop just doing surveillance and recording the problem, and start really taking more of a leadership role," Larson said forthrightly at the conference. "I am speaking to every one of you. Every one of you in the back row — every one of you here — grasp the power that really is yours and you are not necessarily using. Start making administrative and systems changes to assure patient safety," she stressed.

Larson advocated creation of a patient safety "NET," basing the acronym on the phrase "No Excuses/No Tolerance."

"This NET strategy would represent a safety net to reduce health care-associated infections," she said. "I know that none of us can do it alone. On the other hand, we can do a lot more than we think we can and a lot more than we are doing. We have got to get the commitment [from top administration]," Larson continued.

"Our constituency is no longer the staff nurse working in the ICU. It is the top administration where you work, through all levels of staff to implement best practices," she pointed out.

In that regard, the Joint Commission may have done infection control a big favor in changing the default mode from acceptance of noncompliance to expectation of full compliance. While tough-minded, the approach need not lapse into the typical blame-and-shame medical error mode, she noted. "We don’t always do what we are supposed to do, either. We need to help each other, not in a punitive way, but by changing the culture so that the expectation is that you do the right thing and you do it all the time.

"If you don’t do it, you fess up, you fix it, and you move on. We need to empower every staff member to make it happen and correct it when it doesn’t," Larson added.

(Editor’s note: For the complete CDC hand hygiene guidelines and associated materials, go to www.cdc.gov/handhygiene.)


  1. Centers for Disease Control and Prevention. Guideline for hand hygiene in health care settings: Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. MMWR 2002; 51(RR16):1-44.
  2. Huskins WC, Goldmann DA. Controlling methicillin-resistant Staphylococcus aureus, aka Superbug.’ Lancet 2005; 365(9,456):273-275.