Infection Control Today - 04/2002: Success Story

April 1, 2002

Infection Control and Physician Offices: Acing a JCAHO Survey

By Vickie VanDeventer, RN, BSN, CIC

Ashospital services continue to expand, the roles and responsibilities ofinfection control practitioners (ICPs) expand also. Bloomington Hospital andHealthcare System has 297 licensed beds and serves a nine-county area. It hasseveral outlying services including: four labs, six rehabilitation servicesareas, two ambulatory clinics, an anticoagulation clinic, a home healthcareservice, a community clinic, two outpatient psychiatric counseling services, awound care center, an adult daycare center, two radiation oncology centers and10 physician office practices. The ICP is responsible for infection controlpractices in all of these areas.

One of my biggest challenges was preparing the physician offices for theJoint Commission on Accreditation of Healthcare Organizations (JCAHO) survey in1999.

JCAHO standards include physician offices in the survey if the practices meetthree 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 surveyeach 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 forresolved date of issues not met.

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

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

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

I found each office to be cooperative and had the desire to do the rightthing. Education of office staff is very important. Once they understand thereason for the recommendations, they will be willing to comply with yourrequests. The greatest lesson I learned was to work closely with individualoffice managers and office staff. Education will help you gain compliance in aquicker, more efficient manner.

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