Joint Commission: If You Create Infection Control Policy, Make Sure You Follow It
Ending confusion, busting myths
If infection preventionists (IPs) adopt or write up an infection control policy — even if it goes beyond existing recommendations and requirements — The Joint Commission will cite or “score” them if the hospital is not following it. Do not put in word what you will not follow in deed, said Sylvia Garcia-Houchins, MBA, RN, CIC, director of infection prevention and control at The Joint Commission.
“What really gets IPs in trouble [are] policies that go above and beyond the requirements,” she said at the 2023 meeting of the Association for Professionals in Infection Control and Epidemiology (APIC). “When you do that, you get scored on it, and here’s a stunning number: 65% of what The Joint Commission scores is based on the organization’s policy. I can’t tell you what percentage that is from a CMS [Centers for Medicare and Medicaid Services] standpoint, but it’s probably up there, too.”
Other accrediting and regulatory agencies are likely to see this as a breach as well.
“If you wrote a policy, every regulatory body and accrediting body who surveys you will hold you to your policies — even if they are wrong, even if they go above and beyond existing measures and recommendations,” Garcia-Houchins said.
There has been considerable confusion between state and federal regulations, conditions of participation (COP) for CMS, Joint Commission accreditation standards, and evidence-based and consensus documents.
“It’s a hierarchy — it’s not all happening at once,” she said. “You start at the top and you work your way down. Is there an applicable rule or regulation? Then if you are deemed, is there an applicable COP? The bottom line is your chosen evidence-based guideline and consensus documents cannot be less strict than a regulation, a CMS requirement, a [manufacturer’s] instructions for use [IFU], or Joint Commission standards. Now some states have adopted guidelines and consensus documents, so then you have to do it.”
IFUs for medical devices and equipment can include multiple steps and take a complicated route to reprocessing.
“I’ve heard the hue and cry about IFUs,” she said. “I feel your pain. I get it. But the only people who validate the sterilization parameters for those medical devices are the medical device [manufacturers] themselves, or another company who has agreed to go through that costly process to make it happen. So, follow that IFU.”
The infection control policies the facility adopts should be based on an “educated decision” after review of all these factors. Those policies are what The Joint Commission will be expecting IPs to follow.
“An organization’s choices continue to impact your survey outcome,” she said. “It’s a deliberative process, it’s a choice, and it needs to be an educated choice. They’re going to look at your policy.”
The Joint Commission frequently receives calls and emails asking if some infection control measure is now required by the accreditation agency. Most of these are based on misinformation or assuming that a policy adopted at one facility is required for all.
Evidence, Consensus, Flexibility
In a recent article, Garcia-Houchins broke down the difference between evidence-based guidelines and consensus documents:1
• Evidence-based guidance (EBG): Answers questions via a literature search protocol, which identifies relevant articles. The evidence in the articles is abstracted and summarized before a group assesses and formulates recommendations based on consensus. EBGs should provide references that the user can use to evaluate relevance and context for their organization.
• Consensus document: Created by a group and represents individuals’ collective opinions, which may or may not be supported by scientific literature. If a consensus group follows the American National Standards Institute and agrees to its oversight, procedures, approval process, and more, the resulting consensus document becomes an American National Standard. Users may need to review literature to ensure recommendations are supported by evidence.
• Flexibility for IPs: Again, unless required by Joint Commission standards, regulation, CMS, or manufacturer IFUs, organizations may choose which segments of EBGs and consensus documents to incorporate into their practices. For example, the Association of perioperative Registered Nurses uses “should” to indicate a recommended action, “must” to designate requirements mandated by regulation, “may” to demonstrate the action is permissible within the limits of the guidelines, and “can” to indicate possibility and capability.
Endoscope Hang Times, Storage
As confusion continues about certain practices, The Joint Commission is starting to score “leadership” rather than just cracking down on the IP, Garcia-Houchins said. One of these areas is how long can an endoscope hang in storage before you have to reprocess it again? Seven days became the consensus reprocessing interval based more on routine than science, and Joint Commission surveyors are finding a varying range of hang times and methods of storage.
“We’ve done surveyor education and we’ve told them, make sure the endoscope is stored according to the IFU in a way that prevents contamination and per your organization’s policy,” Garcia-Houchins said. “And if it really is an issue, then score leadership for not implementing it.”
However, as endoscope storage and “hang times” continue to be all over the map, The Joint Commission decided to “to stop the madness,” she said.
“We are no longer going to score hang times at all, with the hope that people will stop and think, are we using our resources appropriately?” Garcia-Houchins said. “Instead of reprocessing that scope [arbitrarily] every seven days, please consider reviewing your reprocessing program and [make sure] you’re doing it right the first time.”
Addressing persistent myths, she said The Joint Commission does not require high-efficiency particulate air-filtered endoscope cabinets.
“The key takeaways are to follow the hierarchical approach, and trust but verify,” Garcia-Houchins said. “If somebody tells you The Joint Commission says something, please verify it. I get emails all the time: ‘Is this true?’ And I’m like, ‘No. This is stunning, but it is not true.’”
- Garcia-Houchins S. Developing infection prevention and control processes, policies and procedures: Use of evidence-based guidelines. OR Today. Published July 1, 2023. https://ortoday.com/developing-infection-prevention-and-control-processes-policies-and-procedures-use-of-evidence-based-guidelines/
If infection preventionists adopt or write up an infection control policy — even if it goes beyond existing recommendations and requirements — The Joint Commission will cite or “score” them if the hospital is not following it. Do not put in word what you will not follow in deed, said Sylvia Garcia-Houchins, MBA, RN, CIC, director of infection prevention and control at The Joint Commission.
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