Accreditation

Clean hands or RFI: Joint Commission not playing around with hand hygiene

Briefings on Accreditation and Quality, April 1, 2018

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Thanks to a January rule change, if a Joint Commission surveyor sees anyone who directly cares for patients fail to perform required hand hygiene, that person’s healthcare organization will receive a requirement for improvement (RFI).

Previously, a healthcare organization wasn’t punished for individual hand hygiene failures if that organization had an otherwise compliant hand hygiene program. Well, that was then and this is now: Healthcare organizations have had enough time to train personnel who work directly with patients in how to maintain hand hygiene, the accreditor says.

“While there are various causes for HAI, The Joint Commission has determined that failure to perform hand hygiene associated with direct care of patients should no longer be one of them,” according to the December 2017 issue of Joint Commission’s Perspectives magazine.

Hospitals will be cited under EP 2 of IC.02.01.01, which requires hospitals to use standard precautions as part of a plan to implement infection control and prevention. That’s in addition to continued emphasis on hand hygiene outlined in National Patient Safety Goal 7 to reduce hospital-acquired infections (HAI), as required under NPSG.07.01.01 mandating that hospitals comply with either CDC or World Health Organization (WHO) guidelines on cleaning hands.

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