Accreditation

Tackle the JCAHO’s infection control standards with a group approach

Accreditation Connection, October 1, 2004

Create a committee to comply with the JCAHO's proposed infection control standards, which emphasize a collaborative approach to prevention and control. The revised standards take effect January 1, 2005.

Although the JCAHO doesn't require the creation of a formal interdisciplinary IC committee, it is one way to make sure your hospital complies with the requirements, says Tammy Lundstrom, MD, vice president and chief quality and safety officer at Detroit Medical Center.

"Having a standing committee makes [IC] a priority," Lundstrom says. "If you have a scheduled meeting with a standard agenda, it's more likely that you'll stay on task."

Consider a wide range of committee members. The IC committee at Detroit Medical Center includes physician leaders, administrators, risk managers, pharmacy staff, nursing staff, operating room (OR) staff, and other frontline healthcare workers, Lundstrom says. Organizations can add other representatives depending on the services they provide.

Spaulding Rehabilitation Hospital Network in Boston began an IC task force in January 2001, says Lark Dupont, MSN, RN, CIC, coordinator of IC and patient care services for regulatory compliance.

The long-term acute care and rehabilitation hospital had numerous IC issues, from hand hygiene to equipment disinfection to staff education. Hospital leaders believed the best way to address those issues was through an interdisciplinary committee. "I thought it might work out very well in this setting because I felt IC needs to get down to the program level," Dupont says. "We definitely are a cohesive team."

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