A New Chapter for Infection Control: Joint Commission Standards Overhaul Brings Focus, Flexibility, and Relief

For years, those in the infection prevention and control (IPC) field have been navigating an ever-expanding maze of regulations — many of them well-intentioned, but often overlapping, redundant, or misaligned with the daily realities of healthcare delivery. The COVID-19 pandemic only intensified that pressure, spotlighting both the strengths and the limitations of our systems.

Now, with the Joint Commission's sweeping 2024–2025 overhaul of infection control standards, we finally have a breath of fresh air — and more importantly, a renewed ability to focus on what matters most: protecting patients and healthcare personnel through efficient, meaningful infection prevention.

In a move widely regarded as a "big win," the Joint Commission has reduced the total number of infection control standards across several care settings by up to 73%. This change, long overdue, was praised by industry leaders like Infection Control Consulting Services (ICCS) Founder Phenelle Segal, RN, CIC, FAPIC, who noted that while patient safety must always remain our top priority, overregulation can hinder progress. In her words: "It's a relief for healthcare organizations to see The Joint Commission's process streamlined."

Let's break down what these changes mean and why they matter.

Acute Care & Critical Access Hospitals: From Volume to Value

Starting July 1, 2024, hospitals and critical access hospitals transitioned from 12 infection control standards and 51 Elements of Performance (EPs) to just 4 standards and 14 EPs. The message is clear: it's time to move from paperwork to practice.

Instead of fragmenting requirements across dozens of categories, the new structure consolidates core expectations into four clear areas:

1. Program Infrastructure and Oversight (IC.04.01.01)

2. Execution of Core Infection Control Activities (IC.06.01.01)

3. Organizational Accountability (IC.05.01.01)

4. High-Consequence Infectious Disease (HCID) Preparedness (IC.07.01.01)

What's gone? Redundant documentation, extensive tracking requirements around influenza and vaccine policies, and other check-the-box compliance items that rarely translated to measurable improvements in patient safety.

What remains? Risk-based infection control. Surveillance. Competency. Preparedness for real threats like emerging infectious diseases.

The addition of IC.07.01.01 is particularly vital. It mandates clear plans for the early identification, isolation, and care of patients with high consequence infectious diseases (HCIDs) — think Ebola, SARS-CoV-2, mpox, and perhaps H5N1. For infection preventionists still haunted by the PPE shortages and uncertainty that has largely lingered since 2020, this standard is a welcome — and necessary — step forward.

Behavioral Health: Lean, Focused, and Right-Sized

Behavioral health care facilities will experience their own transformation beginning July 1, 2025, with infection control standards dropping from 11 standards and 40 EPs to just 2 standards and 7 EPs. This is a major streamlining effort designed to reflect the unique risk profile and environment of behavioral health settings.

Gone are the mandates for:

• Assigning a specific infection prevention leader

• Setting annual IPC goals

• Logging certain surveillance and policy decisions now covered under broader leadership responsibilities

Instead, facilities must:

• Maintain written IPC policies

• Conduct annual risk assessments

• Implement core IPC activities

• Develop and act on infection prevention plans based on actual risk

With fewer regulatory hoops to jump through, behavioral health centers can focus on education, hygiene practices, and environmental strategies that truly matter — especially in environments where physical space, mental health needs, and patient behaviors introduce unique IPC challenges.

Nursing Care Centers: Realigned and Modernized

Nursing care centers saw changes that took effect Jan. 1, 2025, as the IC chapter was rewritten to align more closely with CMS Conditions of Participation and CDC Core Practices. While some essential elements remain — such as program structure and surveillance — the rewrite eliminated EPs that were already covered in other domains, like emergency management or environmental safety.

Notably, a new standard (IC.06.01.03) specifically addresses vaccine-preventable disease transmission among both residents and staff. This is a welcome addition, considering the vulnerability of long-term care populations to influenza, COVID-19, and other respiratory pathogens.

Additionally, a powerful step forward comes in the form of antibiotic stewardship. The Joint Commission is implementing Medication Management standard MM.09.01.01, requiring nursing care centers to establish comprehensive stewardship programs — an increasingly urgent need in light of rising antibiotic resistance.

A More Sustainable Path Forward

The broader significance of these changes can't be overstated. For decades, the infection prevention field has pushed to be heard — fighting for resources, time, and institutional buy-in. We've done this while juggling an ever-growing pile of paperwork, policies, and compliance tasks that often added burden without benefit.

Now, with this streamlined model, we have a stronger opportunity to:

• Advocate for real-time education and competency

• Improve high-risk area preparedness

• Make infection prevention visible and actionable at the leadership level

• Focus on what keeps patients — and staff — safe

To be clear, this isn't a free pass to scale back vigilance. If anything, it puts the responsibility squarely on us to do more with less — but in a way that's smart, strategic, and sustainable.

Let's not lose momentum. Let's use this simplification as an opportunity to reinforce best practices, drive meaningful change, and prepare for the next infectious threat — whatever form it takes.

Because as we've all learned, it's not a matter of if, but when.

If your organization is accredited by The Joint Commission and seeking assistance with survey preparation or developing a plan of correction, contact ICCS to schedule your consultation.

The Emerging Bird Flu Threat: An Infection Preventionist's Perspective

By Phenelle Segal, RN, CIC, FAPIC, Founder, Infection Control Consulting Services (ICCS)

For at least two years, the infection prevention and epidemiology community has been assessing the “pandemic of the century,” COVID-19, and what lessons were learned and how we can apply them to strengthen preparation for a future pandemic. We are also trying to determine whether our COVID-19 experiences have improved confidence in our ability to handle a large outbreak or another pandemic, even if it is on a smaller scale than what we experienced from 2020-2022.

One of the first obstacles to effectively preventing transmission of the deadly respiratory virus in 2020 was the lack of personal protective equipment (PPE) — masks effective enough to prevent healthcare workers from inhaling the highly transmissible virus, becoming ill, and possibly dying from the virus. We did our best to work with the limited supplies we had in our possession and pursued efforts to extend their use, like reprocessing or repurposing N95 masks and reusing disposable gowns. These experiences still haunt me today, and I continue to emphasize the need for facilities to ensure they are adequately prepared for the next pandemic, which is inevitable. We must consider where we experienced shortcomings and what we can learn from those difficult experiences. Doing so will enable us to continue growing and improving our preparedness. We know that complacency leads to potential catastrophe. Yes, we are all burned out and tired of the constant reminder that microorganisms are lurking and can strike at any time, but we must remain alert.

I would be in denial if I said that I’m not in the least bit concerned about the ongoing outbreak of avian influenza, also known as H5N1 or bird flu, among poultry and cattle that has become a daily news item. We are fully aware that what begins in animals (zoonosis) can mutate to infect humans, and that would begin the chain of person-to-person spread, potentially in as virulent if not more virulent manner than COVID-19 spread. Of additional concern is the inability to figure out how soon another pandemic may occur, but we know it is inevitable. Questions include whether it will be respiratory in nature, will it present as it did in 2014 with the hemorrhagic fever illness known as Ebola (five years after the H1N1 swine flu), where will it originate from, and can we contain it without huge consequences, as we were able to do with Ebola?

My concerns with H5N1 were present even before I read a recent Medscape article about the increasing H5N1 cases in North America, whereby the article's author highlighted one individual infected in Western Canada and one in Missouri. Both patients had no history of contact with animals, and the source of the virus is unknown. The most recent case, albeit presumptive at this juncture (as of December 13), is a patient hospitalized in Louisiana who had contact with sick and dead birds.

This is all particularly concerning to me and led me to recommend that all ICCS clients and other facilities should, if they have not done so already, begin putting together or reevaluating and updating their pandemic preparedness plans; educating staff about the emerging threat, particularly emergency department and ICU staff; and, equally as important, pulling the pandemic team back together to discuss mitigation strategies based on lessons learned. A key area to concentrate on besides patient placement and other vital steps is PPE and ensuring that, at a minimum, you have stockpiled enough masks, gowns and gloves to respond when we are faced with another outbreak.

I do not have a crystal ball, and neither do any of us in the infection control and prevention field, but we do know that another respiratory pandemic is not a matter of if but when. With increasing cases of H5N1 among animals, and more human cases reported every week, will this virus remain as a zoonotic outbreak or will it soon begin to mutate and spread from human to human?

HICPAC Draft Infection Control Guidelines: Key Considerations

By Phenelle Segal, RN, CIC, FAPIC

In early March 2020, it became clear that, despite decades of planning for a major pandemic, the United States and most of the world were unprepared for a respiratory virus as powerful and harmful as COVID-19.

The CDC's Healthcare Infection Control Practices Advisory Committee (HICPAC) recently drafted updated guidelines to prevent transmission of pathogens in healthcare settings for CDC to review, and they are being met with concern and pushback by patient and staff safety advocates. While this pushback is necessary and warranted, for reasons explained well in this Medpage Today column, we need to also take into consideration the following:

• These guidelines are a draft and forwarded to CDC for review. They are preliminary at this juncture.  

• Cause for concern is valid. Preliminary guidance can appear convoluted and complex, potentially create confusion and possibly result in a repeat of the chaos experienced in facilities as they worked to respond to shifting guidelines during the pandemic, as seen particularly in acute care hospitals and nursing homes.

• Despite the CDC releasing many sets of guidelines during the acute phase of the pandemic (2020-2022), most providers followed previously instilled infection prevention practices to the best of our ability, just with more limited supplies. These practices were taught to us decades before the COVID-19 pandemic began, but there were still significant challenges we had never faced before.

• We should be optimistic that CDC will go back to HICPAC for further discussion before finalizing the guidelines, as the CDC is fully aware of how confusing their COVID-19 guidance appeared.

• We should be hopeful that, at a minimum, companies manufacturing personal protective equipment (PPE) will never experience another pandemic shortage as they did during the pandemic. We hope they will always be able to produce the PPE needed quickly and proficiently. Lessons learned from COVID-19 will hopefully be significant enough to maintain the changes made and fix the problems found in the supply chain. 

• Healthcare workers are naturally geared towards what’s safest and best for all. We should never deviate from this mindset. We need to trust our instincts, and while it is crucial to follow nationally recognized guidelines and standards, we need flexibility and may have to explain to authorities why we have chosen to interpret guidelines in the best possible way. They are, after all, guidelines and not mandates.

• Finally, it is important to note that the Occupational Safety and Health Administration (OSHA) and National Institute for Occupational Safety and Health (NIOSH) release requirements that are not only guidance, but required by law and must be adhered to. These rules could require more stringent infection prevention requirements than what is finalized in the new CDC guidelines.

In conclusion, we must continue to follow science and take precautions that go beyond what HICPAC is advising as the minimum. Doing so will help ensure we do all we can to keep patients and one another safe.

AAMI Issues New Standard on Water Quality for Medical Device Processing

Water quality is an important aspect of medical device reprocessing because of the critical role it plays in ensuring the effectiveness of the process. Water can be a source of microorganisms and chemicals that can negatively affect reprocessing and thus device safety.

The Association for the Advancement of Medical Instrumentation (AAMI) provides expert guidance for settings such as hospitals and ambulatory surgery centers (ASCs) on issues including the reprocessing of instruments and devices. In October 2023, in response to what the organization said was an "extraordinary amount of interest," AAMI published a new standard that establishes requirements for the quality of water used to process medical devices. The standard, ANSI/AAMI ST108:2023, "Water for the processing of medical devices." This new standard revises and replaces AAMI TIR34:2014/(R)2021, which provided information and guidance on water quality for device reprocessing.

AAMI states its new standard:

• identifies the categories of water quality that should be used during each stage of sterile processing;

• provides a risk analysis and establishes roles and responsibilities for processing facilities;

• assesses water quality based on factors such as pH, microbial level, conductivity and other properties;

• establishes maintenance, monitoring and quality improvement procedures for water treatment systems; and

• addresses emergency circumstances such as service interruptions and boil water advisories.

Infection Control Consulting Services (ICCS) assists central sterile processing departments (CSPDs) in maintaining strict compliance for reprocessing, including following nationally recognized guidelines and standards from the Centers for Medicaid & Medicare Services (CMS); accreditation organizations, including The Joint Commission; and organizations like AAMI. The ICCS team has extensive experience with monitoring the processes for pre-cleaning, high-level disinfection, sterilization, environmental cleaning and much more. ICCS also supports organizations that have undergone a survey that identified deficiencies associated with reprocessing and others in putting together a plan of correction.

Contact ICCS to learn what our team can do for your organization.

Should You Perform Hand Hygiene Before Gloving?

By ICCS Founder Phenelle Segal, RN, CIC, FAPIC

An article recently published in the Journal of the American Medical Association (JAMA) highlights a study intended to assess the value of performing hand hygiene prior to donning non-sterile gloves when compared to donning such gloves without prior hand hygiene.

The Infection Control Consulting Services (ICCS) team visits many facilities in the ambulatory surgery setting, and the most frequent violation of proper practices concerns improper hand hygiene. This violation occurs most frequently prior to healthcare personnel donning gloves.

Performing hand hygiene before donning gloves is a practice that's expected, with the Centers for Disease Control and Prevention (CDC) providing specific guidance in the area. Its guidance includes the expectation that staff will perform hand hygiene immediately before touching a patient, performing an aseptic task (e.g., placing an indwelling device) or handling invasive medical devices.

CDC specifies the need for hand hygiene “before touching a patient.” Hence, the ICCS team expects to observe this practice before gloving. Donning gloves is an activity required prior to touching a patient, thus it should be preceded by use of hand sanitizer or handwashing to perform hand hygiene.

ICCS will continue to endorse hand hygiene prior to donning gloves until standards change. While this report is receiving significant media attention, it is important that providers of care do not make a change in their practice based upon the conclusion from a single study and article. We hope to see many additional studies on the subject so we can better determine whether standards should change.

ICCS services include observing practices and providing a written report of findings and suggestions for improvement. As noted, shortcomings with hand hygiene is the most common deficiency we observe in ambulatory settings. Ongoing hand hygiene education is required by the Centers for Medicare & Medicaid Services (CMS) as well as accreditation agencies. Our consultants are also able to assist with the development and provision of hand hygiene education that helps with patient safety and maintaining compliance.