Joint Commission clarifies how some devices will be evaluated for infection control on survey

Accreditation Insider, September 4, 2018

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The Joint Commission (TJC) doesn’t require medical instruments that touch mucous membranes to be stored in individual “peel” packs. It will also stop surveying the duration facilities choose to store devices, so long as manufacturer’s instructions are followed for reprocessing. 

Those are clarifications TJC offered on two elements of performance (EPs) under Infection Control standard IC.02.02.01, in the September issue of its “Perspectives” newsletter. The EPs cover expectations for intermediate and high-level disinfection and sterilization of equipment and devices, as well as storage of those items afterward.

Expect more clarification on how TJC is changing the way it will survey infection control and prevention practices going forward as the accrediting organization continues its crackdown on IC, say experts.

Almost three-quarters of hospitals surveyed in the first half of this year were cited under this standard, according to the list of top 10 challenging standards, also published in the September “Perspectives.”

As usual, the list was dominated by Life Safety and Environment of Care standards, with deficiencies in maintaining fire extinguishing systems and managing utility systems leading as more than 80% of the 646 hospitals facing accreditation surveys failed to meet the challenges. That’s works out to more than 515 hospitals who faced RFIs in those categories just in the first six months of 2018. 

At least 60% of hospitals failed one or more of the top 10 standards. More than 70% faced RFIs under EC.02.06.01, which requires a safe environment and is often cited for problems with ligature risk.

‘Peel packs’ ok but not required

TJC began its clarifications on IC with a discussion of individual packaging for “instruments that touch mucous membranes,” which are considered semi-critical items that must be stored in such a way as to minimize contamination. While individual packaging, often called “peel packs” because they are self-contained in packaging designed to be quickly peeled away, is acceptable, it’s not required, says TJC. Items may be stored in other ways, such as individual clean drawers, as long as they are protected from contamination. Storage must also be consistent with the device’s intended use, among other requirements outlined by TJC.

TJC also said it reviewed guidelines on how frequently endoscopes must be reprocessed if not used after initial disinfection and sterilization. It found that as long as the scopes and accompanying devices are stored so that they are not contaminated and using manufacturer’s instructions there isn’t a problem.

However, the “Perspectives” clarification noted that unprotected, dusty or visibly soiled endoscopes will be cited as well as storage that doesn’t follow manufacturer’s instructions.

— A.J. Plunkett (

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