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5 Steps for a Successful Joint Commission Infection Control Survey
The following article is written by Tom Jordan, RN, BS, CIC, director of infection prevention for Sentri7 from Pharmacy OneSource, part of Wolters Kluwer Health.
The Joint Commission has upped the ante on infection prevention, a move that has many hospitals scrambling to prepare for surveys that now encompass more than just a review of historical outcomes data.
In keeping with an expanded focus on patient safety, the Joint Commission has named infection prevention as a specific focal point going forward. Indeed, the accrediting body has directed its surveyors to specifically target prevention strategies and outcomes during reviews of a facility's infection control policies and procedures.
The pressure is on, but hospitals that take the following five steps can minimize the pain of a Joint Commission infection control survey — and improve their infection control outcomes.
1. Perform a risk assessment
A properly conducted risk assessment creates the framework for a hospital's infection control plan by identifying infections of highest probability and potential for harm. It also identifies areas of weakness, a focal point for Joint Commission surveyors, and guides development of goals and tactics to reduce threats.
A hospital's infection prevention risk assessment (IC.01.03.01) is the cornerstone upon which an infection prevention program should be structured. A comprehensive risk assessment becomes the basis for establishing program goals (IC.01.04), implementation (IC.02) and evaluation (IC.03).
2. Deploy real-time surveillance and data mining
Every infection prevention program is primarily driven by data surveillance, aggregation and analysis. The focus on data includes ongoing measurement of patient outcomes — including hospital-acquired infection trends — as well as the percentage of compliance with intervention processes such as Institute for Healthcare Improvement or hospital-specific "bundles."
When infection surveillance and rate reporting are performed manually, infection preventionists often find little time to facilitate preventive strategies. These time-consuming efforts also result in a "catch up" approach to Joint Commission preparations where IPs find themselves scrambling to compile the required three years' worth of surveillance data. When infection prevention and monitoring is supported by automation, IPs can dedicate significantly more time and effort in infection prevention and education of staff, rather than just spending their time in front of computers collecting data.
Sixty percent of the hospitals interviewed for a recent KLAS report saw a drop in infection rates after deploying a real-time infection surveillance system. KLAS conducts more than 1,900 healthcare provider interviews per month, working with more than 4,500 hospitals. This dramatic drop in HAI rates in these hospitals makes sense, given that these systems eliminate the two primary obstacles to a truly effective infection prevention strategy: not enough time and not enough resources.
One IP at a 200-bed community hospital reported that within four months of implementing an automated, electronic surveillance and reporting system, the amount of time spent performing surveillance dropped by 50 percent. This performance enhancement includes a streamlined process for electronically uploading HAI information into the NHSN database.
Newly created time efficiencies enabled the IP to dedicate significantly more time to prevention strategies and staff education as well as support an ongoing, prospective improvement cycle that aligned with infection prevention program goals. With the ease of report writing provided through the system, the IP was able to keep leadership and front-line staff aware of infection prevention success as well as potential HAI trends.
The alerting functions associated with surveillance technology also had a direct positive impact on infection rates. By notifying IPs to emerging issues in real-time, these systems allowed for faster interventions and clinical decisions based on more accurate and comprehensive patient information.
3. Select the right team
Technology will lay the groundwork for a smooth Joint Commission survey, but it cannot replace a well-managed infection prevention program. When developing the program, accredited hospitals should seek insight from Joint Commission's Survey Activity Guide, which provides guidance on what is expected at the opening of a survey. Also, Joint Commission standard IC.01.01.01 lays out expectations of the individuals managing the infection prevention strategy, as well as development and implementation of policies and procedures.
In general, the most effective infection prevention programs are those that are designed and managed by individuals with specific expertise in infection control and building management. Alongside the expertise of these individuals, real-time electronic infection surveillance software should dramatically enhance efforts of ongoing risk identification, goal measurement, implementation strategies and evaluation.
4. Plan development
The formal infection prevention and control plan, which should ideally be developed based on the results of the risk assessment, is another key to a successful Joint Commission survey.
With the increased focus on HAIs, the plan should include limiting unprotected exposure to pathogens and the transmission of infections associated with procedures. This requires a solid exposure control plan that addresses the use of safety needles, as well as techniques for sterilization, disinfection, skin antisepsis and the appropriate use of antibiotics. Checks and balances should also be in place for monitoring and intervening in each of these areas.
The infection prevention and control plan should include surveillance strategies to minimize, reduce and eliminate the risk of infection. It will also need to address procedures for investigating, acting on and reporting outbreaks. Specifically, real-time surveillance and data mining applications can simplify compliance with Joint Commission's 2011 National Patient Safety Goal 7 as it relates to assessing multidrug-resistant organism and HAI trends.
Facilities should look to Joint Commission standard IC.01.03.01, which identifies the elements a plan must have, and standard IC.01.05.01, which points to the use of evidence-based national guidelines or expert consensus. These include CDC Isolation Guidelines, OSHA Bloodborne Pathogens Guidelines and WHO Hand Hygiene Guidelines.
The results of a solid infection control program supported by surveillance technology speak for themselves. Before the surveillance system was deployed, the 200-bed community hospital previously mentioned averaged five cases of ventilator-assisted pneumonia (VAP) and four cases of central line-associated bloodstream infection annually in the ICU. After deployment and with new strategies in place, it posted 12 consecutive months with no ICU VAPs or CLABSIs.
As a result of the time savings using the electronic surveillance system, the IP director had the time to facilitate multi-disciplinary task force meetings to address the VAP and CLABSI rates. Significantly more time was dedicated to infection prevention strategies and much less time was spent in data collection and NHSN reporting.
5. Evaluation and improvement processes
Like any effective strategic initiative, infection prevention and control methods require constant evaluation and adjusting as new needs are identified.
Joint Commission expectations fall in line with this reality by requiring hospitals to have in place a process for plan evaluation. This should include the establishment of measurable goals, such as decreasing the rate of CLABSIs and VAPs by 50 percent over the course of 12 months.
Continued readiness and success
There are many tactics a hospital can implement to ready itself for a Joint Commission survey. One of the most impactful is deployment of automated surveillance technology, which can put it ahead of the curve for capturing data and intervening when problems are identified.
Hospitals that leverage automated surveillance technology benefit not only from a rapid reduction in the instances of infections, but also from a more efficient and effective prevention strategy. This translates into enhanced patient safety and less painful Joint Commission infection prevention and control surveys.
Tom Jordan, RN, BS, is director of infection prevention for Sentri7 (www.sentri7.com/infection) from Pharmacy OneSource, part of Wolters Kluwer Health. He can be reached at
or (610) 574-4882.
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