which is fine , but you can ’ t automatically swap out one process for another and we had one organization that was taking a whole neuro set and putting it through low-temperature chemical sterilization because it was a set that this provider had been using for 40 years and in their words they were afraid that it was going to just fall to dust if they put it in the sterilizer . IFUs may also be ambiguous or contain conflicting information . My best advice is to contact the manufacturer ’ s technical services department for clarification and get their response in writing because there are some strange things in those IFUs .”
Wiksten encouraged APIC attendees to assess IP & C compliance with the infection control hierarchy , a framework promulgated by the Joint Commission . At the top are rules and regulations , followed by CMS requirements ( for organizations that use Joint Commission accreditation for deemed status purposes or that are required by state regulation ), manufacturers ’ instructions for use , then evidence-based guidelines and national standards , then consensus documents , and finally the healthcare organization ’ s IP & C processes , policies and protocols .
“ Evaluation of your IP & C activities and program to determine if they are working is so important ,” Wiksten emphasized . “ If the activity has targeted the identified risks and goals , provided evidence for continuation of activities , identified issues that need to be resolved and refined implementation of activities , you are on target . Who has knocked it out of the park 100 percent the first time you implemented an activity ? Right . No one . Sometimes it works pretty well , right ? And we ’ re like , ‘ Hey , we got like 80 percent compliance .’ Sometimes you implement an activity and it seems like it ’ s made no improvement , right ? Or sometimes we implement an activity , we see our desired response , but there ’ s an unintended consequence for which we didn ’ t account . And don ’ t forget to communicate your evaluation findings at least annually to the individuals or interdisciplinary group that manages the patient safety program . Some of your organizations might also report that information down to the frontline staff because they want to know how they ’ re impacting HAI rates .”
Understanding the tracer process is essential for IPs , Wiksten emphasized .
“ While they ’ re on a unit , the surveyor is tracing a patient and asking questions about patient flow or they might be looking in the patient ’ s chart , but they ’ re also looking for pieces of equipment in the environment , who ’ s washing their hands when they go in and out of the room , who ’ s putting their PPE on , were contact precautions initiated as per your organization ’ s policy on Friday when positive results were identified as
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 . A culture of safety can affect implementation , where we ’ re looking at the process as a whole and not necessarily that of an individual .” — Tiffany Wiksten , DNP , RN , CIC
opposed to on Monday when the IP came into the office ? They ’ re identifying risks and asking for additional information : Where is the IFU ? What is your policy , process or procedure ? Did staff have the education , training or competency required ? Were the appropriate resources available ? Was the process developed in alignment with the infection control hierarchy ? That may lead them to score additional findings outside of the infection control realm , but what they ’ re looking for is identifying some of the root causes . Understanding the root cause can help your organization to understand and guide your activities and resource allocations . Sometimes it ’ s super simple — we need the thing so we buy the thing , the problem is solved , but how often is that the case in infection prevention and control ? Sometimes it ’ s a marathon and there might be more than a couple of steps along the way , from a short-term fix to a long-term solution .”
Wiksten also addressed a much-anticipated IC chapter rewrite , noting that CMS approved the new infection control requirements and survey processes for hospitals and critical access hospitals . These standards were published in January this year and go into effect this month . The rewrite for non-hospital programs will be implemented in 2025 .
“ There ’ s not really any show-stoppers here ,” Wiksten commented . “ A lot of what you already do is what you ’ re going to continue doing . We rewrote the chapter for hospitals and critical access hospitals to be consistent with the Joint Commission ’ s ongoing initiatives to simplify requirements and provide more meaningful evaluations . We eliminated requirements that do not add value to accreditation surveys , and we focus on the structures that are essential to support quality and safety and provide a
framework for a strong infection prevention and control programs . They will align more closely to law and regulation , such as conditions of participation from CMS and the CDC ’ s core infection prevention and control practices .”
Wiksten continued , “ There are no two healthcare organizations that are exactly the same . You have different staff , different patient populations . I want you to think about how you ’ re going to tailor the activities to your organization . The new infection control chapter has a new numbering system , and the standards have been condensed and reorganized , so we ’ ve gone from 12 standards and 51 elements of performance to four standards and 14 elements of performance , which gives us a lot less variability and subjectivity as to how they will be scored .”
As of July 1 , 2024 the following documentation will be required by the Joint Commission Infection Control Standards :
●The hospital ’ s infection prevention and control program has written policies and procedures to guide its activities and methods for preventing and controlling the transmission of infections within the hospital and between the hospital and other institutions and settings .
●Policies and procedures for cleaning , disinfection , and sterilization of reusable medical and surgical devices and equipment .
●The hospital identified risks for infection , contamination , and exposure that pose a risk to patients and staff and documentation that the risks are reviewed at least annually or whenever significant changes in risk occur .
●Policies and procedures to minimize the risk of communicable disease exposure and acquisition among its staff , in accordance with law and regulation .
●Protocols for high-consequence infectious diseases or special pathogens .
Regarding the structure of the updated infection control standards , Wiksten outlined the following :
●IC . 04.01.01 The hospital has a hospital-wide infection prevention and control program for the surveillance , prevention , and control of healthcare-associated infections ( HAIs ) and other infectious diseases .
●IC . 05.01.01 The hospital ’ s governing body is accountable for the implementation , performance , and sustainability of the infection prevention and control program .
●IC . 06.01.01 The hospital implements its infection prevention and control program through surveillance , prevention , and control activities .
●IC . 07.01.01 The hospital implements processes to support preparedness for high-consequence infectious diseases or special pathogens .
20 • www . healthcarehygienemagazine . com • july 2024