Preparation tips to comply with JCAHO infection control standards

Individual JCAHO surveyors differ in their scoring of IC standards, which makes the survey process more challenging.

Although the IC standards have not changed dramatically in recent years, the JCAHO has identified IC as a big focus area for 2003 and beyond, with surveyors likely to increase their probes of nosocomial infection rates.

Preparation is the key to compliance with these standards, says Teresa Garrison, RN, MSN, CIC, CNLCP, manager of hospital epidemiology programs for BJC HealthCare in St. Louis. Garrison offered tips and identified questions surveyors are likely to ask about IC issues in a presentation during the Association for Professionals in IC and Epidemiology conference in San Antonio in June.

The goals of the JCAHO IC standards are to identify and reduce the risks of acquiring and transmitting infections among patients, employees, physicians, other licensed independent practitioners, contract service workers, volunteers, students, and visitors, Garrison says.

When establishing and following your existing IC program, Garrison recommends taking the following steps:

• Identify the goals for improvement

• Determine who has the authority to shut down your facility, if necessary

• Ascertain your staffing needs

• Establish a staff education plan for your department and all health care workers

• Include a statement on your collaboration efforts with the occupational health department

The first three JCAHO IC standards involve organizations using a coordinated process to reduce the risks of endemic and epidemic nosocomial infections in patients and health care workers (IC.1); using case findings and identifying demographically important nosocomial infections to provide surveillance data (IC.2); and hospitals reporting, when appropriate, information about infections internally and to public health agencies (IC.3). Under the surveillance component of IC.1, Garrison recommends that IC professionals (ICPs) include information on their hospitals’ demographics, patient population, and number of IC staff.

Under IC.3, Garrison suggests that the information reported could include infection rates, trends, clusters/outbreaks, and performance improvement (PI) activities. The groups receiving the information internally and externally could include the IC committee, safety committee, PI council, patient care units, physicians, occupational health, and local departments of health.

Under the first three IC standards, Garrison says JCAHO surveyors are asking the following questions:

• Who is involved in the development of the IC plan?

• What is the method of communicating of the plan with employees?

• How are construction workers hired for projects trained on IC expectations?

• What is the response to surveillance findings?

• What kinds of infections are nurses observing on their units?

• What are nurses doing to reduce infections in their units?

IC.4 requires hospitals to take actions to prevent or reduce the risk of nosocomial infections in patients, employees, and visitors. Examples of compliance efforts could include hand-hygiene campaigns, vaccination campaigns, IC brochures for visitors and patients, and inservice training, Garrison says.

The next two IC standards call for hospitals to take steps to control outbreaks of nosocomial infections when they are identified (IC.5) and for those facilities to design their IC processes to lower the risks and to improve the proportional rates or numerical trends of epidemiologically significant infections (IC.6). When putting together an outbreak investigation plan, Garrison recommends that it be ready for document review. In addition, ICPs need to show surveyors their ability to describe an investigation that occurred in the past 12 months using their process and be able to illustrate “lessons learned” from the investigation process, she says.

Standards IC.6.1 and IC.6.2 deal with management systems that support the IC process, which should include at least one activity aimed at preventing the transmission of epidemiologically significant infections between patients and staff. To receive a score of 1, ICPs should put in place at least one activity, Garrison suggests.

An activity that is planned, but not yet up and running, usually results in a score of 3, she says.

For standards IC.4 through IC.6, Garrison says, surveyors are seeking the following information:

• How staff (not ICPs) prevent infections, which surveyors watch for during tours of patient care areas

• Descriptions of an incident and response to an outbreak within the past year

• How surveillance data is used to improve processes within your organization

• Identification of processes that exist to prevent patient-to-staff transmission

• The ways in which the hospital supports IC (i.e., equipment, software, or clerical assistance)

There are numerous JCAHO leadership standards that tie into improving performance in IC, Garrison says, noting that ICPs “need to educate your leaders about your [IC] plan.”

ICPs, according to Garrison, must focus their efforts on the following leadership standards:

• LD.1—leaders plan for the provision of care

• LD.1.4—setting PI priorities based on data

• LD.3—integrating and coordinating services

• LD.4.1—leaders understand PI

• LD.4.2—approach to PI

• LD.4.3—important processes that affect patient outcomes, including nosocomial infections and outbreaks/clusters

• LD.5—leaders ensure that an integrated patient safety program is put in place throughout the organization

• LD.5.1—sentinel events

Like the leadership standards, some environment of care (EC) standards contain IC components, Garrison says, including the following:

• EC.1.1—hospital plans for a safe environment

• EC.1.1.1—plans for worker safety

• EC.1.3—plans for managing hazardous materials and waste

• EC.1.4—the organization has an emergency management plan

The JCAHO in mid-June provided a sneak peek at its 2004 standards by making them available for viewing online.

The new standards, which take effect January 1, 2004, are available at www.jcaho.org/accredited+organizations/2004+standards.htm. Organizations should receive the published standards this November.

Since 2000, the Joint Commission’s standards review task force has examined each standard for all of the JCAHO’s accreditation programs, excluding assisted living, critical access hospitals, networks, and office-based surgery.

The JCAHO revamped the standards with the following goals in mind:

• Reduce the number of standards by eliminating those that are no longer relevant

• Improve the clarity and relevance

• Lessen paperwork and documentation burdens to demonstrate compliance

• Align the standards requirements—now called elements of performance—with surveyor assessment and scoring protocols

In doing so, the JCAHO consolidated standards from the assessment and care of patients (TX) chapters, the continuum of care, and education chapters into a new “provision of care” chapter.

The TX medication standards now appear in a “medication management,” or MM chapter.

The JCAHO says the resulting standards are not “new.” Modifications embody deletions, consolidations, or clarifications of existing standards.

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