You’ re looking at not only implementation of the activities themselves, but implementation of your auditing and surveillance activities so you can keep your finger on the pulse and identify when a defect in the process is happening, either occurring more frequently, or it’ s occurring across multiple areas or departments and maybe you need to revisit that process to shore it up.”
delivered, such as standard precautions, hand hygiene, environmental cleaning, and transmission-based precautions. But also, activities that address the specific risks that you identified. You’ re looking at not only implementation of the activities themselves, but implementation of your auditing and surveillance activities so you can keep your finger on the pulse and identify when a defect in the process is happening, either occurring more frequently, or it’ s occurring across multiple areas or departments and maybe you need to revisit that process to shore it up.”
Wiksten added,“ Using the information that you’ ve captured from surveillance and auditing, your process data and your outcome data, you must evaluate it to see what it’ s telling you. Also think about who you report it to and then take it and incorporate it back into your planning for the next year, because maybe it’ s going to change your priorities. Maybe you’ re going to see you’ re doing well in one area and it’ s time to shift priority or focus to another area where there are bigger risks. When you’ re looking at implementation, make sure your processes are aligned with the infection control hierarchy.”
Among the most frequently cited CMS Condition-level deficiencies are infection prevention and control and antibiotic stewardship programs and surgical services. According to the Joint Commission, a hospital must have active hospital-wide programs for the surveillance, prevention, and control of HAIs and other infectious diseases, and for the optimization of antibiotic use through stewardship. The programs must demonstrate adherence to nationally recognized infection prevention and control guidelines, as well as to best practices for improving antibiotic use where applicable, and for reducing the development and transmission of HAIs and antibiotic-resistant organisms. Infection prevention and control problems and antibiotic use issues identified in the programs must be addressed in collaboration with the hospital-wide quality assessment and performance improvement( QAPI) program. Examples of condition-level deficiencies are: Process errors observed when staff prepared ultrasound probes / transducers that contact mucous membranes or nonintact skin for high-level disinfection; non-compliance with the organization’ s transmission-based precautions policy in multiple locations within the organization; relative humidity levels in operating suites were not consistent with national standards; and critical air pressure relationships were not correct.
For surgical services, the Joint Commission requires that services must be well organized and provided in accordance with acceptable standards of practice. If outpatient surgical services are offered the services must be consistent in quality with inpatient care in accordance with the complexity of services offered. Examples of condition-level deficiencies are process errors observed when staff prepared surgical instruments for sterilization( cleaning / decontamination, pack and prep, etc.); sterilized surgical instruments ready for use in disrepair; and instruments not disassembled prior to sterilization when required by manufacturers’ instructions for use.
Frequently cited infection prevention activity observations, according to Wiksten, include:
• Not following regulations / requirements: For example, the dishwasher temperature was not monitored as required by state food code or washing of hospital linens lacked evidence of a process by which to achieve and maintain proper water temperatures required by state regulations.
• Not following manufacturers’ IFUs: For example, failure to use surgical and / or skin preparation products and antiseptics in a manner consistent with manufacturers’ instructions for use
• Not following organization process, procedure and policy: For example, surgical staff were wearing earrings that were not covered as required by the facility’ s operating room attire policy.
• Not implemented for all relevant components / functions: For example, the organization’ s procedural attire policy was not enforced for all providers performing central line insertion, across multiple locations / departments in the organization.
• Ineffective leadership oversight: For example, facility leaders did not effectively manage the implementation of infection control activities.
Wiksten pointed to the need to break down silos to achieve improved communication and collaboration that involve all components involved in infection prevention and control activities as well as organization leaders and / or quality assessment and performance improvement program to address infection prevention and control issues. Regarding the communication of infection prevention-related data and issues, Wiksten advised IPs to consider three groups: Who needs to know; who wants to know; and who else would benefit.
“ These groups may be dictated by law and regulation,” she noted.“ They also may be dictated by organizational policy and procedure, and the timeframe may depend on the situation.” She emphasized that addressing infection control issues for hospitals and critical-access hospitals requires communication and collaboration with the quality assessment and performance improvement program. For nursing care centers, home health, assisted living, behavioral health, laboratory, and office-based surgery, the organization must develop and implement necessary action plans to address infection control issues and improve its infection prevention and control program. The organization evaluates and revises its plan as needed.
Applying Joint Commission Standards for Special and High-Consequence Pathogens
In the APIC session,“ Identify, Isolate, Inform: Applying Joint Commission Standards for Special Pathogens,” presenters Christa Arguinchona, MSN, RN, CCRN-K, manager of the Special Pathogens Treatment Center( Region 10) and Cassie Prather, MPH, CIC, clinical educator for Providence Sacred Heart Medical Center, explained the Joint Commission infection prevention and control standards for high-consequence infectious diseases or special pathogens.
A special pathogen is an agent that is highly infectious, highly contagious, and highly hazardous, and is likely to cause a high-consequence infectious disease( HCID). An HCID is acute infectious disease that has a high case-fatality rate, may not be readily available, effective treatment or prevention; and has ability to spread in the community and / or within healthcare settings. HCIDs often require enhanced and coordinated healthcare workers, healthcare systems, and public health responses to ensure that itis managed safely and effectively.
Arguinchona explained that in 2014- 2015 with the Ebola outbreak in West Africa,“ That’ s when the CDC implemented a tiered system of how we receive those patients into our healthcare facilities, treatment centers, assessment centers, and frontline facilities.
24 • www. healthcarehygienemagazine. com • jul-aug 2025