Infection control findings on the rise at The Joint Commission

Accreditation Monthly, October 24, 2007

Plenty of anecdotal evidence is showing a sharp rise in the Joint Commission full survey requirement for improvement (RFI) findings for three standards in the "Infection Control" (IC) chapter. 

The first is IC.5.10 EP 1, which calls for the healthcare organization to conduct a formal evaluation of its IC program at least annually or whenever risks change significantly. The evaluation may  reveal a need to revise the goals or intervention strategies of the program. As an "A" EP, it is quite simple for the surveyor to ask the organization to produce written evidence of a previously conducted  formal evaluation along with conclusions or recommendations for making no changes to the program or to revise its program to include new goals or strategies to address changing risks.

The second finding is IC.2.10 EP 1 and EP 2.  In these elements, the organization is to conduct a criteria-based risk assessment and review the assessment at least annually or as changes in risks warrant. The assessment is to identify risks for the transmission and acquisition of infectious agents in the hospital based on factors such as geographic location, programs or services offered, and characteristics of the population served.  EP 1 is a "B" EP, which means the assessment should be designed using the principles of good process design and, in this case, it means creating a criteria-based risk assessment tool that resembles the familiar Hazard Vulnerability Analysis tool used in the assessment of Emergency Management (Disaster) hazards and risks.  Note: The Greeley Company has assisted a client in developing an assessment tool, and it is available to download at Keep in mind that IC.2.10 EP 2 is an "A" EP, which makes it easy for a surveyor to probe and score "yes/no" if the organization is unable to produce written evidence that the risk assessment was formally reviewed at least annually.

Finally, IC.9.10 EP 1 is showing up as an RFI in a number of surveys. This EP requires that the effectiveness of the organizations infection prevention and control activities are evaluated on an ongoing basis and that the results of the evaluation are reported to the "integrated patient safety program" at least annually.  Once again, as an "A" EP, this is an easy yes/no "gotcha" for the surveyor when the organization is unable to produce written evidence that the safety committee (or similar committee that integrates safety) received a report about IC effectiveness at least annually. The key point here is that the report needs to go beyond, or outside, the traditional IC committee.

Speaking on behalf of my colleagues at The Greeley Company, any one of us would be happy to assist you with bulletproofing your organization against receiving an RFI for one or more of these three IC standards. We specialize in helping to craft policies and effective processes designed specifically to fit your organization. It may also be time to schedule an Unannounced Survey Vulnerability Visit by one of our Greeley mock survey teams. For more information, please call Stacey Koch, Director of Client Relations, at 888/749-3054, ext. 3193.

Most Popular