"Oh, no! The Joint Commission is here!” The infection preventionist’s heart starts pounding, and her mind starts racing. She has heard only terrifying things about surveys by The Joint Commission.
But should infection preventionists (IPs) be nervous when a representative from The Joint Commission comes to do a survey? To find out, Infection Control Today® (ICT®) went to the source.
Sylvia Garcia-Houchins, MBA, RN, CIC, director of infection prevention and control at The Joint Commission, talked with ICT about what The Joint Commission does and does not do, how long it has been around, and what IPs should know.
Listen to the entire interview and the many more topics Garcia-Houchins discusses concerning The Joint Commission.
ICT: Please explain what The Joint Commission does and what its background is.
Sylvia Garcia-Houchins, MBA, RN, CIC: The Joint Commission is the largest accreditor of health care organizations in the United States, meaning we accredit hospitals…but we also accredit other programs, such as ambulatory surgery centers, Bureau of Primary Health Care, and some of the Veterans Health Administration [hospitals]. We also do US military [institutions] in foreign countries.
Schedule of Interview
0:26: What The Joint Commission (TJC) does and its background
4:38: What Sylvia Garcia-Houchins wishes IPs knew about TJC.
14:03: Explanation of what TJC can do and is not cut and dry.
16:25: The Clarification Period during survey: Clearing up misunderstandings.
20:09: How has TJC changed since the beginning of COVID-19? More explanation of what TJC does and does not do.
27:50: What a good survey consultant does for the facility.
30.19: Who pays for TJC’s services? Why are TJC’s services needed?
32:37: What education does a surveyor need to have?
34:34: How to ask questions to TJC.
35:41: Are questions to TJC about a survey anonymous? How can questions be answered?
We accredit, which is very different than some people think. We’re not inspectors; we’re surveyors. We don’t walk around with our little checklist and say, “Check, check, check.” We look for high-risk issues. We look for process issues. That’s an important bit of background for The Joint Commission: It’s about processes.
We don’t look at the individual equipment. We don’t say, “Oh, you have that one. You can’t use that one.” A survey by The Joint Commission would never say that, or it should never say that. Because we don’t survey you [about] your equipment. Or say that you need to use a specific brand. We don’t even say—except in a few instances—that you must follow a particular evidence-based guideline or consensus document. [A survey] is a personalized accreditation process, making sure that you’re following rules and regulations that apply to you in your state and your location, that if you’re being accredited…to get Medicare and Medicaid funding, that you’re following the Center for Medicare & Medicaid Services (CMS) Conditions of Participation1…that you’re following any of the regulatory requirements, such as United States Food and Drug Administration (FDA) rules about reprocessing medical devices. That’s the core of what we do.
[For example:] You decide that you’re not going to allow staff members to have fingernails longer than a quarter of an inch, which is a CDC category 2 safe practice, but is not required by the CDC. If you’ve decided that’s what you’re going to do, then we’re going to survey and say, “Are you following what you say you’re going to do? Are you following your own policies?” That’s part of the survey process.
What we’re doing is trying to identify places where your organization has risk. It might be a risk to a patient, it might be a risk to a visitor, it might be a risk from a regulatory standpoint….We’re trying to be there to point out those things that are risk factors. At the end, we provide a Survey Analysis for Evaluating Risk (SAFER) matrix,2 which is a tool that’s been [in use since January 2017]. That categorizes what we found. And it says, “We only found it in a few places, it’s very limited, or we found it everywhere.” And [it categorizes it as] low, medium, or high risk.
[The Joint Commission has] been in business for more than 70 years…. We’ve developed and grown, and we are a leader in providing the best guidance and survey process to identify risks.
ICT: What do you wish IPs knew about The Joint Commission?
SG-H:The most important thing that IPs need to know is that the risk assessment is not the solution to everything.
In April 2019, we published for our customers The Joint Commission Perspectives, and it’s available if you go to The Joint Commission website, and on the Infection Control page for anyone to see how we clarified scoring of infection control standards. And it’s following a systematic approach. The answer is going to change depending on where you are in the country.
There is a place for risk assessment. Risk assessment is when you are identifying issues that may pose a risk and deciding how much of a risk. For example, our surveyors use what’s called “tracer methodology.”3 IPs do this every day, all the time. You walk around your organization, and you look at things, and you say, “That doesn’t look [right]. Maybe I should figure out if it is OK to put that sharps dispenser there. They are 2 ft from the ground in a pediatric area.” What’s the first thing you’re going to do? You’re going to say, “Is there any rule or regulation that applies?” In my state, there isn’t. So is there a CMS requirement? I look at the CMS State Operations Manual4, and it says nothing about where I must position my sharps. Next, I look at the building code. There’s nothing in there that says my sharps container can’t be 2 ft from the ground. And then I look at the manufacturer’s instructions. They give me some guidance, but they don’t say, “Put it here.” And then maybe I go to an evidence-based guideline or something else, such as National Institute for Occupational Safety & Health, which might tell you the optimal placement, but that’s just a recommendation.
I am doing a risk assessment. But what do I consider the risk? For instance, what if I’m in a pediatric hospital, and a little girl puts her hand into the sharps container? That’s a much different risk than an area where an adult phlebotomist who is in a wheelchair is drawing your blood and needs the container to be at a certain height to safely dispose of that needle. That’s when you start doing risk assessment. That’s what I’m trying to make sure infection preventionists know. I see survey reports where the survey states they didn’t follow the manufacturer’s instructions for sterilization, they’re not following the parameters. And the infection preventionist says, “We did a risk assessment and decided that those parameters didn’t work.”
Why would you deviate from something that’s a validated parameter that the FDA requires that a manufacturer state? We still [see staff members] doing risk assessments because someone has 15 things to sterilize and they decided they’re going to do it at the average temperature. Or maybe the doctor says, “Something’s happening to the finish on this instrument. I don’t want you to sterilize at that temperature. I want you to do it at a lower temperature.”
The Joint Commission cannot say, “Sure, use this product.” Instead, I have spent 3 years educating IPs that just because it’s biologically compatible…doesn’t mean it’s functionally compatible. It’s sometimes difficult for the IPs to understand that. And so we’ve come up with scoring examples. For instance, if the surveyors see an organization using a product to clean a glucometer, [for example,] that it is not within the manufacturer’s instructions for use, we ask them to take it to the next step. Is this going to kill bloodborne pathogens? Because that’s the big risk. They’re using a product with a label that says, yes, it’s effective against bloodborne pathogens, and then you score at a lower risk from an infection control standpoint. And you say the organization was not following the manufacturer’s instructions. You classify the risk that way.
It was eye-opening for me as an IP to come to work at The Joint Commission 4 years ago. Nearly everything I thought about The Joint Commission went out the window. I used to work for an organization where the accreditation manager said, “You will not ask The Joint Commission a question because then the surveyor is going to come and survey for that.” I assure you, if you send the standards interpretation group a question, it is not going to your surveyor. You’re going to get the best possible answer. If you’re not happy with the answer, you write back and say, “That’s not the answer I was expecting. Could you please help me a little more?”
The Joint Commission is very transparent about what is a requirement. If you hear about something The Joint Commission supposedly said, come to The Joint Commission and ask. On our website, https://www.jointcommission.org/, is “Ask a standards interpretation question.”5 You can put your question in there and get it answered.
[But] why don’t people do this? [Instead, they] ask somebody who asked somebody because it seems easier. And they don’t realize it’s not a good question or a good answer. There are nuances to the answer, and they end up making a decision that impacts their organization negatively on the survey because they asked a friend about a policy or listened to a lecture that someone gave or watched [a video] on YouTube. Come to the source. We’re more than happy to answer your questions.
ICT: Is it anonymous?
SG-H: No, it is not anonymous. You put in your name, your contact number, and your email. [You may be] worried if you use your work email that there will be a record. But you don’t have to worry.
As I said at the beginning, we all want the best possible care for our patients….Accidents happen. And risks are real. If we can get rid of some of those risks, it’s great.
ICT: What kind of education does a surveyor need?
SG-H: At least a master’s degree. You must have a higher degree and leadership experience. Our surveyors have all been leaders in health care. They understand the implications of “If I say something, X is the outcome,” and they must have a knowledge of the program they are serving. For example, I could not be a home care product surveyor, I have no background in that. You must have experience in the areas in which you will be a surveyor. You can’t have worked only in an ambulatory surgery center and expect to be in a hospital service. We can’t teach that kind of background or knowledge. Then there’s a whole training program. It’s lifelong training.
This interview has been edited for length and clarity.