The necessary evil of accreditation surveys are a very real challenge for today's infection control practitioners (ICPs). Moreover, the turn of 2006 brought with it the practice of unannounced surveys. Gone are the days of focusing on preparedness for just a few months. These unannounced arrivals make it more important than ever for infection control (IC) practices to remain sterling throughout an organization at all times and in all facets.
The unannounced survey process is really designed to make sure that an organization is prepared for survey and is therefore a safer organization at all times, asserts Louise Kuhny, RN, MPH, CIC, associate director of standards interpretations with the Joint Commission on Accreditation of Healthcare Organizations (JCAHO).
Along with these unannounced surveys comes a survey methodology called tracers.¹ In this method, the surveyor follows a patient or process through the continuum of care. IC procedures, as well as the environment of care (EOC), are areas addressed during this process.
There are two different kinds of tracers, Kuhny explains. There are individual patient tracers and system tracers. What we will do with an individual patient tracer is we will go through and we will follow a patient through the organization. We will also follow anything that coordinates the care of that patient through the organization. Well also want to take a look at the areas which contribute to that patient, but perhaps where the patient isnt directly going. For example, if a tracer patient is going to surgery, we may take a look at how the instruments for that patient were sterilized. We may go down to the central sterile department and take a look at that. We may also take a look at the pharmacy, look at the preparation of medications, and then of course we would look at any isolation practices used for the tracer patient.
Then, we do an IC systems tracer, where we take a look at the entire IC function. The ICPs will have an opportunity during that tracer to discuss how theyve met the requirements particularly that of (JCAHO standards) IC.2.10 through IC.5.10 in terms of their risk assessment, setting goals, establishing priorities, implementation, and then evaluation.
Gail Bennett, RN, MSN, CIC, executive director of ICP Associates LLC, and the author of the book Infection Control Compliance Guide: Understanding the JCAHOs Standards, says the best practice is to have continuous survey readiness, because it is even more critical now that we have unannounced surveys, she points out.
Kuhny says the IC function is continuously evaluated on all the various tracers and ICPs, as well as all other healthcare workers (HCWs) and staff members, should be prepared to answer questions during any of those times. Every employee in the organization should be able to speak to their role in IC, she asserts.
Bennett agrees, All staff should be aware of IC policies and procedures and should be competent in implementing them. Having department managers monitoring for compliance is an important aspect of any good IC program. Some other important areas include staff having knowledge of isolation precautions, use of personal protective equipment, sharps injury prevention, and biomedical waste management.
With each passing year, surveyors have increased focus on various aspects of IC. Kuhny shares some helpful considerations for 2006.
I cant say that we are focusing on any one particular area of our standards this year. Of course we do have a National Patient Safety Goal (NPSG) that is IC-related and that is NPSG 7A, which is hand hygiene. This has been around since 2004, but despite that fact we do still see some issues with this. The issues that we see are both in terms of actual compliance, so we do live observations while we are there at the organization, but also organizations should ensure that their policies and processes for hand hygiene meet all of the 1A, 1B, and 1C recommendations from the Centers for Disease Control and Prevention (CDC).
In addition to that, she continues, NPSG 7B talks about sentinel events related to IC, and organizations should be prepared to discuss how they would determine if a healthcare associated infection (HAI) fell into those parameters and then what action they would take.
In terms of a focus, I cant really identify anything that we are focusing on except for just a good grasp of our standards, and NPSG 7A and 7B.
In terms of the changing nature of IC, several of our standards require that organizations keep up-to-date with a risk assessment. Standard IC.2.10, in the introduction to that standard, it talks about risk assessment and it says as these risks change over time, sometimes rapidly; risk assessment must be an ongoing process. Then, Standard IC.6.10 talks about managing an influx or an ongoing influx of potentially infectious patients. That also talks about keeping up-to-date with current trends in infectious disease.
Those are the things that are a focus and may be a little newer, but besides that, its a good, healthy infection control program that is built upon the requirements of the entire program, which are laid out in IC.1.10, she shares.
Bennett says the current JCAHO standards for IC are very specific, and she shares some of the hot spots for survey. She advises a comprehensive written IC plan. That plan should include:
- An assessment of the geographic location and community environment
- Analysis of the hospitals infection data
- Care, treatment, and services provided by the facility
- A description of prioritized risks
- A statement of the programs goals based on the risks
- A description of the hospitals strategies to minimize, reduce, or eliminate risks
- A description of how the strategies will be prioritized Other considerations include:
- Having a process to detect infection related sentinel events and performing a root cause analysis when you do detect one
- Having a policy and a process for managing an influx of patients with infectious diseases
- Having compliance with national recommendations and standards of practice for IC (or appropriate rationale for not following those recommendations)
- Compliance with NPSG for hand hygiene
- Having documentation of the qualifications and competencies of the person(s) responsible for IC
- Gathering input from leaders relating to the IC plan
- Having appropriate resources for IC
- Having appropriate IC practices as demonstrated during the patient tracer
ICPs have a network to help them stay abreast of what the surveyors are focusing on, Bennett offers. That network may be formal such as discussion or presentations at local APIC (Association for Professionals in Infection Control and Epidemiology) or statewide meetings, or informal through telephone conversations with other ICPs. In addition, publications like JCAHO Perspectives as well as the JCAHO Web site can be very helpful. However, the best resource is the JCAHO standards themselves. As the standards are updated, ICPs must review them carefully and implement the intent of the standards. If we have questions about the standards, we can contact JCAHO and get our technical questions answered.
Loretta Litz Fauerbach, MS, CIC, director of infection control at Shands Hospital at the University of Florida, at Gainesville, and a member of the Society for Healthcare Epidemiology of America (SHEA), recently completed an unannounced survey in March. She shares her experience and offers advice.
The surveyors watch for IC practices during the entire survey, she points out. By the time they do the infection prevention and control interview they have noticed practice throughout the organization. This year, they seem to focus on hand hygiene, compliance with isolation and precautions, surveillance data, interventions to reduce infections, and the IC assessment and plan for the year. They also wanted to know about management of construction and renovations and the ICRA (infection control risk assessment) process. The surveyor also asked about immunizations and occupational health follow-up, including influenza and varicella vaccine. Additionally, the surveyor wanted us to talk about our surge capacity, our risk assessment, and planning and partnership with local public health officials during emergency situations.
Fauerbach says that during the IC interview, the surveyor wanted to hear from everyone in the room about their role and what their infection prevention and control has done. They are looking for assessment and planning, and interventions to address problems, she explains. They emphasize communications to all parts of the organization. They also asked about administrative support and staffing needs. We could respond that a new 0.5 FTE (full-time employee) was recently approved in the middle of a budget cycle because of the desire to do more monitoring and surveillance. This new staff was a good example of support. We had to also explain who did my evaluation as the director of the program the goal was to make sure that the person evaluating the ICP was qualified to make a determination of the individuals competency.
Fauerbach continues, The very first day, the survey team asked for our surveillance data. I would make sure that you have a way to present it to them in an organized fashion using graphs and charts. Along with the data, an interpretation plus recommendations for action should be included for them to review. At this time, I would also try and provide the IC assessment and plan to show why you are doing the surveillance that you are.
Bennett says that if IC has such a detailed written IC plan as is required by JCAHO, performance improvements should be fairly easily noted. In the IC plan, the IC program develops goals, strategies to implement those goals, and they measure the effectiveness of those strategies, she explains. So improvements (attainment of goals) should be reflected in the plan. Preferable surveillance data will reflect the surveillance plan developed as part of the written IC plan and will reflect the risks identified. It should be collected in a timely manner and there needs to be evidence of appropriate analysis of the data with subsequent actions taken if needed.
She adds that presenting the data in a format that is easy to interpret, such as charts and graphs, can be helpful and is often appreciated by the surveyors.
Kuhny offers further advice on sharing the data. In terms of display of the data, we dont have specific requirements on that, but when you look at IC.5.10 in terms of the evaluation of the effectiveness of the program, the data should be analyzed in a way where the organization knows which data points they need to take action on. In other words, there must be some sort of statistical tool to objectively decide at what point, if you are above your goals, you are going to take action. At what point do you become concerned?
If ICPs are not experts at data analysis then they should really work with their quality management department to help them understand how they can best analyze and then display that data so that the display of data is a tool for them to use to know when they need to do something differently; when they need to take action, she adds.
Overall, Kuhny says all IC operations are very organization-specific. She suggests reference to IC.2.10 EP.1, which requires an evaluation of the risk according to geographic location, community environment, results of previous data, as well as care treatment and services provided.
Also, she says the surveyor will ask for the IC surveillance data from the past 12 months. The caveat on that is, we can look back up to 36 months, she warns. Id like to give you a couple of short tips that would really help, but whats really important is that the ongoing nature of the IC program is healthy all the time, Kuhny offers. If they are doing that, they will be ready for survey when the surveyors come.
Bennett agrees, offering, If we base our IC program on sound epidemiologic principles and incorporate the JCAHO standards as they continually evolve, our programs should provide the protection that we desire for our patients and meet the JCAHO standards at the same time.
Continual readiness, a good, healthy IC program, effective education for staff members, and the proper use of surveillance methods and data, all will help to ensure the IC methods of an organization passes survey inspection. As Fauerbach points out, The key to a successful visit is an involved and compliant facility staff and medical staff. No longer can IC rely on the paperwork to validate their program. Everyone at every level is part of the process. As the old saying goes infection control is everybodys business!
1.) Camplin, Roger. JCAHO-Being Ready Instead of Getting Ready. American Society for Healthcare Environmental Services Annual Conference & Technical Exhibition. September 26, 2005.
IC Survey Preparedness at a Glance
- Be sure that infection prevention and control initiatives and key concerns are communicated throughout the organization
- Make sure the individual employee knows his or her responsibility to the infection prevention and control program
- Make sure data and assessments are communicated up through the organization to the board of directors
- Be able to demonstrate interventions and improvement based on data trends and emerging pathogens
- Be able to discuss, with rates, immunization practices and requirements for the facility -- for staff, medical staff, students, and volunteers
- Be able to discuss exposure management and interventions
- Keep your surveillance activities and interventions up-to-date and consistent know what you did to intervene and the impact
- Make sure all policies and procedures are current and that the staff are compliant with them as a routine standard, not just as a JCAHO is coming so get prepared kind of thing
- Enforce hand hygiene compliance and compliance with the prohibition of artificial fingernails. Ask patients what they see
- Be able to document your infection control risk assessment activities for renovation and construction
- Be sure you have done a complete and thorough risk assessment and analysis from the previous year to drive your IC plan for the coming year. Be sure to communicate that throughout your reporting structure
- Keep your data up-to-date and in a user-friendly format (i.e. graphs, charts, pictures and other highlighted information)
Source: Loretta Litz Fauerbach, MS, CIC, director of infection control at Shands Hospital at the University of Florida, at Gainesville, and a member of the Society for Healthcare Epidemiology of America (SHEA)