Infection Control

SSI prevention measures include evidence-based guidelines

Briefings on Infection Control, September 1, 2009

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The final National Patient Safety Goal (NPSG) that deals with a specific infection is NPSG.07.05.01, concerning surgical site infections (SSI). As with NPSG.07.03.01 and NPSG.07.04.01, accredited facilities must meet specific requirements at certain points throughout the year.

As with the previous two NPSGs, the first milestone expected by The Joint Commission was for a facility’s leadership to assign a person to oversee and coordinate the development, testing, and implementation of this NPSG by April 1, 2009. In most facilities, leaders will assign this responsibility to the IP, epidemiologist, or an IC consultant.

By July, this designated person should have a defined work plan in place that identifies resources, accountability, and a timeline for fully implementing this plan. The hospital must pilot test this plan in one clinical unit by October 1 and fully implement it across the facility by January 1, 2010. Hospital leaders should make the person who manages the SSI program responsible for ensuring that the facility implements an active program for identifying SSIs, analyzes data about them, and regularly provides information to those people who can use the information to improve the quality of care. The person must also see that the hospital incorporates evidence-based practices into the program.

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