Infection Control Today - 04/2002: Success Story

Infection Control and Physician Offices: Acing a JCAHO Survey

By Vickie VanDeventer, RN, BSN, CIC

As hospital services continue to expand, the roles and responsibilities of infection control practitioners (ICPs) expand also. Bloomington Hospital and Healthcare System has 297 licensed beds and serves a nine-county area. It has several outlying services including: four labs, six rehabilitation services areas, two ambulatory clinics, an anticoagulation clinic, a home healthcare service, a community clinic, two outpatient psychiatric counseling services, a wound care center, an adult daycare center, two radiation oncology centers and 10 physician office practices. The ICP is responsible for infection control practices in all of these areas.

One of my biggest challenges was preparing the physician offices for the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) survey in 1999.

JCAHO standards include physician offices in the survey if the practices meet three of the following criteria:

  • Have common medical or professional staff
  • Share the same human resources department
  • The organization's policies and procedures are applicable to the service provided
  • The organization manages significant operations of the service
  • The organization applies its performance improvement program to the entity and has authority to implement actions intended to improve performance at the point of service
  • The service's patient records are integrated into the organization's patient record system
  • The organization bills for services provided by the service

Before visiting each office, I developed a form to use as a guide to survey each practice. There are columns on the form to indicate if each issue was met, not met or not applicable, a space for additional comments, and a space for resolved date of issues not met.

The survey reviews issues for employees and patients. I met with the practice administrator and attended the office managers' meeting to share the survey with them and explain the purpose of my involvement.

The survey was divided into four sections: general criteria, bloodborne pathogen issues, equipment handling and isolation. The section titled general criteria reviewed issues such as reporting communicable diseases, handwashing, cleaning products and temperature logs. The bloodborne pathogen section reviewed staff training, exposure policy, sharps containers and personal protective equipment (PPE). Equipment handling reviewed single-use patient equipment, high-level disinfectant use and sterilization. Isolation reviewed the plan for caring for patients with tuberculosis or other communicable diseases.

The opportunities for improvement identified were common in several of the practices and included: use of proper cleaning products, proper use of gluteraldehyde, biological spore checks for tabletop sterilizers, separation of refrigerator contents, maintaining temperature logs and storage of supplies.

I found each office to be cooperative and had the desire to do the right thing. Education of office staff is very important. Once they understand the reason for the recommendations, they will be willing to comply with your requests. The greatest lesson I learned was to work closely with individual office managers and office staff. Education will help you gain compliance in a quicker, more efficient manner.

Vickie VanDeventer RN, BSN, CIC, is an infection control practitioner at Bloomington Hospital and Healthcare System in Bloomington, Ind. She is an active member in APIC Indiana Chapter 76 and currently serves as president-elect. She gave a presentation at the APIC Indiana spring conference pertaining to her work in physician office practices.

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