Infection Control Requirements Among the Most Challenging for Joint Commission-Accredited Organizations in 2018

The Joint Commission has released its report on the top five most challenging requirements for 2018. These are requirements identified most frequently as "not compliant" during surveys and reviews from Jan. 1, 2018, through Dec. 31, 2018.

Unfortunately, it comes as no surprise to Infection Control Consulting Services (ICCS) that infection control standards hold one or more spots for several of the accreditation organization's programs.

Ambulatory Care Accreditation

For the ambulatory care accreditation program, infection control standards were the most challenging and fourth most challenging. IC.02.02.01 (The organization reduces the risk of infections associated with medical equipment, devices, and supplies.) took the top spot with more than 60% non-compliance. Coming in fourth was IC.02.01.01 (The organization implements infection prevention and control activities.) at nearly 46%.

Office-Based Surgery Practice Accreditation

Office-based surgery practices had similar results. IC.02.02.01 (The practice reduces the risk of infections associated with medical equipment, devices, and supplies.) occupied the top spot with about 64% non-compliance. In fourth was IC.02.01.01 (The practice implements infection prevention and control activities.) at about 29%.

Hospital Accreditation

For the hospital accreditation program, IC.02.02.01 (The hospital reduces the risk of infections associated with medical equipment, devices, and supplies.) took the fifth spot at nearly 71%.

Home Care Accreditation

For home care organizations, IC.02.01.01 (The organization implements the infection prevention and control activities it has planned.) was the second most challenging standard with more than 40% non-compliance.

Nursing Care Center Accreditation

Infection control standards occupy two spots on the nursing care center program's list. Coming in second was IC.02.01.01 (The organization implements its infection prevention and control plan.) with about 39% non-compliance while IC.02.02.01 (The organization reduces the risk of infections associated with medical equipment, devices, and supplies.) occupies the fifth spot with about 29% non-compliance.

Commentary from the Field

These results are consistent with observations made by ICCS consultants during on-site visits in 2018. ICCS serves facility types including ambulatory care, behavioral health, critical access hospitals, acute care hospitals and office-based surgery practices. ICCS services include assisting organizations with survey preparation and complying with infection control requirements from the Centers for Medicare & Medicaid Services (CMS), The Joint Commission, AAAHC, HFAP, DNV and AAAASF.

Study: Improper Personal Protective Equipment Practices Spread Contamination

A new study shows that when healthcare workers do not properly remove their personal protective equipment (PPE), the likelihood of bacterial contamination increases significantly.

The study was performed at a tertiary-care teaching hospital. Researchers monitored and evaluated samples taken from 125 healthcare workers — mostly nurses or physicians — in four adult intensive care units caring for patients colonized or infected with a multi-drug resistant organism (MDRO), according to a Society for Healthcare Epidemiology of America (SHEA) news release.

The study's results were published in SHEA's Infection Control and Hospital Epidemiology journal. Findings included the following:

Nearly 40% percent of workers made errors in removing their PPE, including gowns and gloves, when evaluated by Centers for Disease Control and Prevention (CDC) guidelines. This was despite the fact that, as the release notes, a significant majority of the workers had undergone training on appropriate methods for donning and doffing PPE within the past five years.

  • Following patient contact, 36% of workers were contaminated with an MDRO.

  • After removing PPE, more than 10% were contaminated on their hands, clothing or equipment.

  • Workers who made multiple PPE-removal errors were more likely to be contaminated after a patient encounter.

"Based on these findings, we should reevaluate strategies for removing PPE, as well as how often healthcare workers are trained on these methods," said Dr. Koh Okamoto, a lead author of the study, in the release. "An intervention as simple as education about appropriate doffing of PPE may reduce healthcare worker contamination with MDROs."