APIC 2024 Update
Joint Commission Scored Observations and Standards : What ’ s New This Year
By Kelly M . Pyrek
a presentation at the annual conference of the Association for Profession-
In
als in Infection Control and Epidemiology ( APIC ), “ The Joint Commission : Infection Control Standards Update ,” Tiffany Wiksten , DNP , RN , CIC , reviewed frequently scored and high-risk infection control observations as well as explained the application of the Joint Commission ’ s infection control standards to various healthcare settings .
Wiksten noted that of the top 10 infection control-related findings among all programs in 2023 , the top five are all implementation-related standards , beginning with the IC . 02 designation , including Standard Precautions , Low-level Disinfection , High-level Disinfection , and Storage . The other findings in the top 10 are planning and evaluation standards with the designation of IC . 01 and IC . 02 , respectively .
“ Implementation standards are what are scored most frequently , which makes sense , because when you have a plan or a risk assessment or goals , you have one plan . You ’ ve done one risk assessment , you have one set of goals , you ’ ve done one evaluation . So naturally those are not going to be scored as frequently as surveyors observing the implementation of your infection prevention and control activity ,” Wiksten said .
“ The highest-risk observations made by surveyors related to high-level disinfection and sterility , often where immediate threat to health and safety lives ,” she added . “ But there is also significant risk related to standard precautions , and that ’ s due to use of a fingerstick device on more than one patient . The two programs that we see this in most frequently are home health and behavioral health .”
Wiksten reminded the audience that the Joint Commission categorizes observations by surveyors by hospitals and critical access hospitals , ambulatory healthcare , nursing care center , home health and behavioral healthcare . “ The top five observations for 2023 were mostly implementation standards for acute-care and ambulatory healthcare facilities , but nursing care center risks and home health risks were scored ,” Wiksten said . “ When we look at behavioral healthcare settings , most of the standards that are scored for 2023 were related to program-planning standards . So , our colleagues in behavioral health might need a little assistance with developing their infection prevention and control programs . For the last three years for hospitals and critical access hospitals , the top five scored infection control findings were all implementation ; but year after year , we see high-level disinfection and sterilization scored the most frequently , followed by storage — all those pesky expired things that we find every day . Looking at ambulatory , our top five are all implementation standards , but for the last three years the No . 1 most frequently scored observation is standard precautions , followed by high-level disinfection and sterilization .”
Moving into common challenges in IP & C , Wiksten clarified that what the Joint Commission is looking for is the implementation of the activity . “ What we ’ re seeing is you ’ ve got your program , you ’ ve got your plan , you ’ ve got your risk assessment , you ’ ve got your goals . But our biggest opportunities are when our staff implement those activities , the staff doing the work in real time , so implementation of infection prevention and control activities should be practical and involve collaboration between departments and staff . Everyone who works in the hospital should have a role and hold each other accountable , right ? Accountability is huge . Important infection prevention and control information should be available to both staff and patients .” Wiksten continued , “ A culture of safety can affect implementation , where we ’ re looking at the process as a whole and not necessarily that of an individual . The Joint Commission supports a safety culture , encouraging leaders to readily and willingly participate with care-team members in initiatives designed to develop and emulate safety culture characteristics . So , they see safety issues as problems with organizational systems and that their employees see those adverse events and close calls as providing information-rich data for systems improvement .”
She added that successful implementation of infection control activities is multi-factorial .
“ The first thing you need to do is identify the infection control risks in your organization . We all have basic standard activities that we implement standard precautions , transmission-based precautions , but you may be implementing other infection control activities to mitigate specific risks identified in your organization . Next you must develop your activities in alignment with an infection control hierarchy that provides resources , so make sure that resources are available to the staff so that they can perform their job duties . That includes things like having access to policies and procedures , access to manufacturers ’ instructions for use , and having the right tools and equipment to do their job . So , think about your people and sterilization — they need to have the right brushes and flushing devices . Your staff on the floors need to have the right PPE in the right sizes . And then providing the education , training and competency checks that those staff need to be able to implement their job functions as intended .”
Wiksten continued , “ So , what are the key elements of implementation that surveyors are looking for ? One , that you have a process as an alignment with the infection control hierarchy . Two , that staff have access to the resources that they need . Sometimes surveyors will go into a soiled utility room where they ’ ve seen the staff members bring that biohazard box after a procedure has been done , they ’ ll set it on the counter and the organization ’ s policy , process and procedure says we must spray those instruments with a product to keep them moist . And the surveyor goes OK , and they both look at each other for a second . And they ’ re like , ‘ Well , where ’ s your products ?’ And they ’ re like , ‘ Well , we don ’ t have any .’ How are they going to follow the 18 • www . healthcarehygienemagazine . com • july 2024