Joint Commission Offers Tips for Survey Readiness

<p style="LINE-HEIGHT: normal; MARGIN: 0in 0in 0pt; mso-pagination: none; mso-layout-grid-align: none" class="MsoNormal"> <span style="FONT-FAMILY: 'Arial','sans-serif'; FONT-SIZE: 10pt">Healthcare-associated infections claim the lives of 99,000 people every year, according to CDC statistics, and several nationwide initiatives are linked to reducing the risks of adverse events and increasing patient safety.</span> </p>

By Karin Lillis

Healthcare-associated infections claim the lives of 99,000 people every year, according to CDC statistics, and several nationwide initiatives are linked to reducing the risks of adverse events and increasing patient safety.

With the national focus on patient safety, the Joint Commission has put the spotlight on infection prevention, says Louise Kuhny, RN, MPH, MBA, CIC, clinical educator for accreditation and certification operations for the Joint Commission. Weve asked surveyors to specifically target this area, she says, as they review an organizations infection control policies and procedures.

Kuhny shares her suggestions to help infection preventionists avoid panic and anxiety that often comes with surprise Joint Commission surveys.

Be ready at the opening conference.

Joint Commission surveyors expect infection control to be readily available at the start of the process. Kuhny stresses the importance of keeping that information up-to-date through the last 36 months. You wouldnt want to run around printing everything out or rushing to compile data when surveyors have arrived.

The Joint Commissions Survey Activity Guide is available to all accredited organizationswhich have an individual login to the Joint Commission extranet site. A wide variety of resources are available for download. Infection preventionists should pay particular attention to whats required at the opening conference of a Joint Commission visitespecially the infection control system tracer and individual patient tracers.

For more information: http://www.jointcommission.org/assets/1/18/2011_SAG.pdf

Be certain infection control surveillance data is up-to-date.

We know infection preventionists are understaffed in many cases, but not having [current] surveillance information is not OK, Kuhny says. If youre handing us surveillance data that is many months behind, that raises red flags. Surveyors expect that information to be in a perpetual state of readiness so the hospital can pinpoint problem areas, track trends and adjust practice and policy where its necessary.

Make sure the hospitals written infection control plan is customized and pertinent to the individual hospitals needs.

Risk assessment, for some reason, is especially tricky, Kuhny says. Most often, that portion is not pertinent to the particular organization or its missing some of the required elementsincluding identifying risks based on geographic location, community and population served. Joint Commission standard IC.01.03.01 lays out what elements an infection control plan must have. Be sure youve gone through that standard and can point to each risk, Kuhny says. As surveyors look at the infection control plan, theyll ask for evidence-based guidelines to back up that process.  

Be familiar with the Joint Commissions 2011 National Patient Safety Goal 7, which focuses on reducing the risk of healthcare-associated infections.

Specifically, the goal targets hand hygiene, multidrug-resistant organisms, central line-associated bloodstream infections and surgical site infections. Kuhny notes a few common misconceptions about individual parts of the goal. One of the most frequent misunderstandings about bloodstream infection prevention: the Joint Commission requires whole-house surveillance on this issue. Every patient who has a central line needs to be part of the surveillance programnot just those in the ICU, she says. For surgical site infection prevention, the most frequent problem is hair removal before a medical procedure. We still find a number of surgeons preparing to use razors instead of clippers or depilatories, as the guidelines permit, Kuhny says.

For more information: http://www.jointcommission.org/assets/1/6/2011_NPSGs_HAP.pdf  

Pay particular attention to the healthcare organizations sterilization and disinfection processestwo hot button issues.

Our surveyors just received very in-depth education on sterilization, so theyll be very much in tune with that portion of the survey. Patients undergoing surgery have a reasonable expectation to have sterile instruments, she says. Surveyors will visit the hospitals central sterilization processing department, ask employees how theyre performing each process and what guidelines theyve based their practices on. Your staff should be able to point to the organizations policy and procedure to indicate theyre aware of what guidelines are used. She especially advises infection preventionists new to the hospital to go through the organizations policies and procedures to make sure theyre following nationally required guidelines. Key resources include the CDCs Healthcare Infection Control Practices Advisory Committee (HICPAC) and the Association for the Advancement of Medical Instrumentation.

For more information: http://www.cdc.gov/hicpac and http://www.aami.org 

Practice shoe leather epidemiology.

Visit every area of the hospital where sterilization and high-level disinfection happennot just the CS department, Kuhny says. 

If an infection preventionist has not worked in the endoscopy department, for example, shes not going to know how to process a scope. Pull the HICPAC guidelines and go through them step by step, she says. Make sure staff members are following each part of the process. Manufacturers requirements and instructions also contain critical information.  

Focus on improving flu vaccination rates among staff and independent practitioners.

Joint Commission standards require critical access hospitals, hospitals and long-term care facilities to offer influenza vaccination to staff and licensed independent practitioners. Since flu immunization for healthcare workers is a priority in several national initiatives, the surveyors will focus heavily on the hospitals vaccination rates. In December, for instance, the U.S. Department of Health and Human Services unveiled its Healthy People 2020 campaign, the nations new 10-year goals and objectives for health promotion and disease prevention. That includes a 90 percent vaccination rate among healthcare workers, Kuhny says.

In 2008, the Joint Commission Resources launched the Flu Vaccination Challenge to help increase flu immunization rates among healthcare workers above the national average of 49 percent. During the 2009-2010 flu season, the challenge yielded an average immunization rate of 76 percent --a 13 percent increase over the rate reported in 2008-2009 and 27 percent above the national healthcare workers flu vaccination average. For the 2010-2011 flu season, initiative is continuing to raise the bar among healthcare workers to increase their flu vaccination rates. Hospitals and other organizations are encouraged to achieve one of three tiers75 percent (bronze level), 85 percent (silver level) and 95 percent (gold level). Surveys dont always happen in influenza season, so be able to show your vaccination rates and how youre improving over timeregardless of what time of year, Kuhny adds.   

Collaborate with employee health to make sure the hospital is adhering to Joint Commission immunization requirements.

In particular, hospitals might not be up-to-date with current vaccination guidelines, as required by Joint Commission standard. Resources like the CDCs Advisory Committee on Immunization Practices provide schedules and charts pertaining specifically to healthcare workers. Perhaps do a spot audit of employee health files and make sure those are in compliance with the organizations policies and procedures as well as the current guidelines, Kuhny says. Surveyors might pull the personnel file for many of the people theyve interviewedfrom respiratory therapists, nurses and physicians to aides and housekeepers. Theyll also ask for the employee health file on each of those peoplegoing through to make sure immunizations and TB tests are up-to-date.

For more information: http://www.cdc.gov/vaccines/recs/acip/default.htm  

Its OK to ask questions.

Dont be afraid to approach our surveyors. Theyre familiar with Joint Commission guidelines and willing to discuss things with youpotential requirements of improvement. Feel free to have open conversations with them. The surveyors are there to help your organizationand they will listen to you, Kuhny says.  

Karin Lillis is a freelance writer.

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