The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) remains committed to its focus on infection prevention. Because healthcare-associated infections are a major source of morbidity, mortality, and cost, one of the most important safety initiatives you can undertake is prevention.
Q How's infection prevention surveyed?
A JCAHO assesses compliance via individual patient tracers and an infection control (IC) system tracer.
[white diamond suit] In an individual patient tracer, the surveyor follows the patient's care through the organization, as well as any functions that contribute to the patient.
[white diamond suit] For an IC system tracer, the surveyor looks at the entire infection prevention function. The IC practitioners discuss how they meet JCAHO standards.
Q What's expected in terms of a plan?
A The plan is the backbone of the infection prevention program. JCAHO standards IC.2.10 through IC.5.10 are designed as a continuous process. The IC plan documents each healthcare organization's IC program, as required in IC.1.10 EP 9.
Leaders analyze the organization's IC plan (IC.1.10 EP 9) to evaluate its IC system design. The plan should require written documentation of each step in the cycle, including:
[white diamond suit] a description of prioritized risks (correlates to IC.2.10)
[white diamond suit] a statement of the IC program goals (correlates to IC.3.10)
[white diamond suit] a description of the hospital's strategies to minimize, reduce, or eliminate the prioritized risks (correlates to IC.4.10)
[white diamond suit] a description of how to evaluate strategies (correlates to IC.5.10).
Q What's the survey focus?
A Surveyors evaluate both direct patient care issues, as well as the infection prevention system as a whole. If an issue is identified during tracer activity, the surveyor drills down to help leaders understand the underlying system cause. Examples of this include:
[white diamond suit] The surveyor observes a lapse in isolation technique on an inpatient unit. After noting this lapse as an observation (IC.4.10 EP 4), the surveyor may ask questions regarding staff education (HR.2.10 EP 3), isolation surveillance (IC.2.10 EP 3), and accountability (LD.2.20 EP 2).
[white diamond suit] The surveyor notes that rates of infection following orthopedic surgery have increased. He or she may ask about outbreak management (IC.1.10 EP 6), medical equipment processing (IC.3.10 EP 5), testing of sterilizers (EC.6.20 EP 5), and collaboration with sterilization staff (IC.8.10 EP 1).
[white diamond suit] The surveyor notes delays in reporting surveillance data (IC.2.10 EP 3). In addition, the surveyor may investigate the program's evaluation process (IC.5.10 EP 5), the program's management (IC.7.10 EP 1), and resources available (IC.9.10 EP 2).
Q How's hand hygiene surveyed?
A National Patient Safety Goal 7A requires compliance with all class 1A, 1B, and 1C recommendations contained in the Centers for Disease Control and Prevention (CDC) hand hygiene guidelines.
Q What can we do to prepare staff?
A The best way to prepare for the survey is to practice tracers regularly. Assume the role of a surveyor, observe IC practices, and interview staff. Also, practice drilling down. Based on the information gathered, form a plan for improvement. Doing so will prepare you for JCAHO survey success and will improve patient safety.