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Keep it clean: Handwashing hygiene is a key to JCAHO success

Nurse Leader Weekly, August 28, 2006

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With staff handwashing being such an easy item to observe, expect this National Patient Safety Goal to remain a high priority during accreditation surveys.

Hospitals can safely assume that surveyors "are going to pay specific attention to how well facilities are following the recommendations on the patient safety goals," said Vicky Zelenka, RN, CIC, director of infection control (IC) and clinical epidemiology at McLeod Health in Florence, SC. Zelenka spoke during the HCPro, Inc., audioconference "JCAHO IC standards a year later: What to expect from the trenches."

"So you can expect that hand hygiene would be uppermost in [the thoughts] of the surveyors" and that they will note how well hospitals enforce the Centers for Disease Control and Prevention's handwashing guidelines and also pick up on whether staff understand the provisions, she added.

During her pair of surveys in 2005 and 2006, hand hygiene was under constant inquiry, said Zelenka.

"All of [the surveyors] observed hand hygiene, even if their focus wasn't infection control," she said. Use of gloves, hand gels, and soap and water all received equal attention. Surveyors observed staff when they were taking vital signs or charting patients to see whether they wore gloves, took them off at the right time, and washed their hands after removing them.

Focus on these documents

Hospitals should have infection surveillance data from the past 12 months and documentation on how they report that information, said Terrie Lee, RN, MS, MPH, CIC, director of clinical epidemiology and employee health for the Charleston (WV) Area Medical Center, who also spoke during the audioconference. Her hospital underwent a JCAHO review in March.

The IC team at Charleston Area Medical Center decided to keep a notebook that contained easy-to-follow tabs and a table of contents, Lee said. When surveyors asked to see Lee's IC policy documents, it was usually in response to a behavior that they observed to ensure that employees followed hospital policies.

A common pitfall for hospitals is when staff actions don't reflect internal policies, which may lead to a citation from the JCAHO.

Other documents that surveyors might review include

• an IC plan
• an annual IC risk assessment
• IC committee meeting minutes
• surveillance methodology and data
• any root-cause analyses
• a Failure Mode and Effects Analysis

Editor's note: This excerpt was adapted from Briefings on Patient Safety, September 2006, HCPro, Inc.

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