Pathogen Pulse: Hot Button Issues The Joint Commission Is Zeroing in on for 2025

Pathogen Pulse with Isis Lamphier, MPH, MHA, CIC

As an infection preventionist (IP), I frequently hear my colleagues asking each other, “When is your Joint Commission survey?” or “What did The Joint Commission focus on when they surveyed your building?” These conversations reflect a common undercurrent of anticipation, and sometimes anxiety, that comes with preparing for survey readiness.

Recently, while attending an infection prevention conference and reflecting with colleagues, I noticed recurring themes in what surveyors are paying close attention to. Across different organizations, the same issues kept surfacing. These “hot topic” areas represent not only adherence checkpoints but also critical opportunities to strengthen our infection prevention practices. Based on these discussions, I’ve identified the top five items the Joint Commission is currently emphasizing, which are issues that every IP should be ready to address during their next survey.

1. Ultrasound Gel, Ultrasound Gel, Ultrasound Gel

In May 2025, the CDC issued an urgent alert emphasizing the safe use of ultrasound gel: Use only sterile, single-use ultrasound gel products labeled as “sterile” for percutaneous procedures. This applies to situations such as the placement of central and peripheral IV lines, amniocentesis, paracentesis, tissue biopsy, and surgical procedures. Health care providers performing ultrasounds and ultrasound-associated procedures must be trained on the appropriate use of gel products.

For IPs, this is a crucial discussion point during The Joint Commission surveys. Be prepared to speak to:

• Where single-use packets are used in your facility.
• Where reusable bottles are in circulation and why.
• How your team ensures adherence to manufacturer instructions for use (IFUs).

Reusable bottles may have contraindications printed on the label, often noting that use with high-risk patients could lead to infection if contamination occurs. Facilities must also have processes in place for monitoring expiration and open dates for reusable bottles. Some products require reusable bottles to be labeled upon opening and discarded after 28 or 30 days.

2. High-Level Disinfection Machines and Ultrasound Probes

Surveyors are paying close attention to how facilities manage high-level disinfection (HLD) machines and the traceability of ultrasound probes. This includes ensuring:

1. Complete documentation of probe disinfection cycles.
2. Verification and recordkeeping of testing results.
3. Proper cleaning and disinfection of the HLD machine itself, both inside and out.
4. Routine machine maintenance and adherence to the manufacturer’s instructions for use.

Ultrasound probes that require HLD must be processed correctly every single time. IPs should be ready to discuss how their facility ensures compliance with IFUs, maintains traceability from patient to probe to disinfection cycle, and monitors ongoing machine performance. Gaps in any of these areas are common findings during surveys.

3. Operating Room and Sterile Processing Department (SPD)

The Joint Commission is also focusing heavily on instrument reprocessing in the operating room (OR) and sterile processing department (SPD). Surveyors want to see that items are being reprocessed according to validated standards and manufacturer guidance.

One of the key challenges facilities face is instrument lifecycle tracking. Many devices can only undergo a limited number of reprocessing cycles before they must be replaced. Surveyors are asking:

1. How do you track the number of times these items have been reprocessed?
2. Do you know the maximum number of uses allowed for each device in your inventory?
3. What safeguards are in place to prevent overuse of instruments beyond their safe lifespan?

IPs play a critical role in bridging communication between SPD, OR staff, and leadership to ensure adherence, maintain patient safety, and prevent costly survey citations.

Infection Prevention Knowledge of Frontline Staff

As of May 2024, The Joint Commission has changed how infection control is evaluated. The dedicated, in-person “Infection Control Session” has been replaced with an evaluation of infection control practices woven into each surveyor’s individual tracer sessions. This means that infection prevention is no longer confined to conversations with the infection prevention department. Instead, frontline staff are now being asked questions that used to be reserved for IPs, such as:

1. Do you know how to access your facility’s infection control policies?
2. Can you identify where to find infection prevention data (eg, central line-associated bloodstream infection, catheter-associated urinary tract infection rates)?
3. How does your unit use infection control data to improve patient safety?

For IPs, this shift reinforces the importance of staff education and empowerment. Every team member, from nurses to techs, needs to be able to answer basic infection prevention questions confidently and accurately. Ensuring staff are aware of where to find policies, understand data, and can articulate how infection prevention relates to their daily work will be a key point of survey readiness moving forward.

5. High-Consequence Infectious Disease Preparedness

A new area of focus for The Joint Commission is preparedness for high-consequence infectious diseases (HCID) such as Ebola, Severe Acute Respiratory Syndrome, Middle East Respiratory Syndrome, and mpox. Surveyors want to see that facilities have clear, practical protocols for early identification, rapid isolation, screening, and staff protection should a suspected case present. IPs should be ready to describe how their organization prepares frontline staff, ensures access to appropriate personal protective equipment, and maintains readiness plans. HCID preparedness is not just about meeting standards; it’s about protecting both patients and health care workers in the face of emerging threats.

While this list is by no means comprehensive, it provides a quick snapshot of the hot topics The Joint Commission is currently emphasizing. Staying proactive in these areas not only strengthens your infection prevention program but also builds confidence heading into survey. If you ever have a question regarding survey readiness, you can contact The Joint Commission using its website. Best of luck maintaining survey readiness!