The standards are written in a way to be very broad and provide that framework for which each organization develops their infection prevention and control program and activities.“ Why is that important? Because every organization is like a snowflake; no two are exactly the same. You’ re not in the same location, you don’ t have the same building, you don’ t provide the same care and services, you don’ t serve the same populations, and you don’ t have the same staff.” |
requirements and provide more meaningful evaluations of hospitals.“ That meant getting rid of redundant standards and elements of performance that created more busy work and didn’ t provide meaningful outcomes for organizations,” she said.“ We want to focus on the structures that are essential to support quality and safety and identify a framework for a strong infection prevention and control program.
Wiksten also noted that the streamlined standards also align more closely to the Centers for Medicare & Medicaid Services( CMS)’ Conditions of Participation( CoPs) and Conditions for Coverage( CfCs), as well as the Centers for Disease Control and Prevention( CDC)’ s Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings.
“ The standards are written in a way to be very broad and provide that framework for which each organization develops their infection prevention and control program and activities,” she said.“ Why is that important? Because every organization is like a snowflake; no two are exactly the same. You’ re not in the same location, you don’ t have the same building, you don’ t provide the same care and services, you don’ t serve the same populations, and you don’ t have the same staff. So, we use different gowns, we buy different gloves, we use different syringes and disinfectant wipes, we have different pieces of equipment. Therefore, you can’ t write standards and elements of performance that are a one size fits all for everybody.”
Wiksten continued,“ Joint Commission likes to say,‘ We eliminated a ton of standards and elements of performance,’ but does that mean we’ re looking at fewer things? No, we’ re looking at the same things, really and truly. So, when we trimmed our standards in elements of performance, hospitals went from 12 standards and 51 elements of performance down to four standards and 14 elements of performance. Nursing care centers went from 13 standards and 49 elements of performance down to two standards and 10 elements of performance. And behavioral healthcare is going from 11 standards and 40 elements of performance down to two standards and seven elements of performance. What that means for you is that there’ s going to be a lot less scored so you don’ t have to send a clarification and say,‘ This should have gone under storage and not disinfection, right?’ Because we don’ t necessarily have to clarify where these things are going anymore because all things will go under implementation standards. That makes compliance a lot easier because it’ s going to confirm that you have a policy and process in place, but staff were observed
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not following it.”
Wiksten reviewed the five big buckets of the updated infection control standards. The first is foundational requirements for infection prevention and control program / activities.“ This includes the individual in charge of the infection control program, if you’ re a hospital, a critical-access hospital, a nursing care center, or if you’ re in a smaller setting, somebody who’ s responsible for managing infection prevention and control activities,” she said.“ This is where policy and procedure development lives. This is where your program plan lives.”
Second is leadership support.“ Leaders need to support infection prevention and control,” she noted.“ You can’ t do it alone, right? The more leadership support you have the more effective your program is going to be. They provide you with resources and personnel to do the work, whether it’ s in infection prevention and control, environmental services staff to keep your hospital clean, or enough staff in sterile processing to ensure that all of your instruments are processed and ready for use for patients the next day. Leadership support also means helping the infection prevention and control department address issues that arise – which is the third category of implementation of activities. So, maybe you’ re starting to see across the organization that transmission-based precautions are not being implemented as intended or according to your policy. Or maybe you’ ve identified that your washer-decontaminator is going down every third day and maybe we need to start looking at a new piece of equipment. So, it’ s about escalating issues up to leadership, so it can help fix the problem, help develop and implement risk-mitigation plans, and evaluate the effectiveness of plans that we’ ve implemented and revise them if necessary. And if you’ re a smaller program, sometimes this means developing action plans to address your specific noncompliance or defect that you’ re finding. Implementation of activities is implementation of all your policies and procedures and following the manufacturers’ instructions for use, but implementation of auditing and surveillance activities also falls in this bucket. You need to know what’ s going on in your organization.”
The fourth bucket is quality assurance, performance improvement / action plans.“ You need to have a way to identify when processes are starting to lapse or you’ re finding defects in the process,” Wiksten said.“ And then last for hospitals and critical access hospitals and our lab colleagues, is the new standard referring to high-consequence infectious diseases. So, making sure that if you’ re a hospital or critical access hospital, you’ re identifying,
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The more leadership support you have the more effective your program is going to be. They provide you with resources and personnel to do the work, whether it’ s in infection prevention and control, environmental services staff to keep your hospital clean, or enough staff in sterile processing to ensure that all of your instruments are processed and ready for use for patients the next day.” |