that an instrument or piece of equipment should be taken out of service .
➋ It is necessary for an IP to thoroughly understand his or her primary resources . Some of the most important resources include :
• Manufacturer instructions for use for any medical device , supply or equipment that needs to be or is used to clean , disinfect , or sterilize .
These resources provide basic information to guide development of any organization ’ s infection control plan .
➌ IPs should perform tracers like a Joint Commission surveyor does . Surveyors don ’ t follow a checklist ; they ask open-ended questions and determine through the answers how to identify risks . For example , an IP might perform a “ procedure ” tracer . In doing so , he or she selects a device in sterile processing that is used by a clinic . Then the IP asks the clinic nurse or medical assistant what procedure ( s ) are conducted in the clinic with that device and with what additional equipment or devices does he or she prepare for the procedure ? This provides context for how the devices are used .
IPs should watch how the healthcare organizations staff prepares a room for the next patient . They should also ask for instructions for use and if they are easily available . Then , review them to determine if items were used , discarded , or reprocessed in accordance with the instructions . Make sure that the reprocessing level and intended use match for everything used . If an item is cleaned , disinfected , or sterilized , follow it through the process , ask open ended questions without assuming know the answer . Don ’ t make assumptions . Ask clarifying questions , like : Does it make sense ? IPs should make sure that they thoroughly understand the processes involved and identify any risk points . Then they can use the information to identify other “ threads to pull ” prioritize and mitigate risks .
➍ Access resources that The Joint Commission offers through
www . jointcommission . org Scroll to the bottom of the page to find a link to the Joint Commission Connect website . Every Joint Commission-accredited healthcare organization has access . If your organization cannot access , ask your accreditation manager to give you access . Through this website you can access :
• E-dition is the electronic version of the Joint Commission standards and all IPs should access to determine the standards that apply to their organization .
• Perspectives is the official publication of the Joint Commission . If an infection control process or scoring example is addressed in this publication it is important that the IP or accreditation team evaluate organizational compliance . A recent example is Blood Glucose Monitoring and Insulin Administration , which was published in the Consistent Interpretations section . The CDC has issued multiple alerts that unsafe practices during assisted monitoring of blood glucose and insulin administration place people at risk of transmission of bloodborne viruses ( HBV , hepatitis C virus , and HIV ) and have since 2008 , linked these unsafe practices to outbreaks of viral hepatitis related to healthcare , including personal care homes , assisted living , home care agency , and long-term care . Review of scoring has identified knowledge gaps among providers and / or leaders that have resulted in unsafe practices and subsequent escalation to an Immediate Threat to Health and Safety . For deemed organizations , CMS requires that state and accreditation organizations refer any infection control breaches that could potentially expose patients to the blood or bodily fluids of another to the appropriate state public health authority ( S & C : 14-36-ALL REVISED 10.28.16 ). In July 2021 , the Joint Commission will publish clarification on how compliance with reprocessing of ultrasound transducers will be scored . Prior topics include water management , personal protective equipment , surgical attire , and food and drink in patient-care areas . IPs should review scoring examples to identify if interventions are needed to ensure patient safety .
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Ask a Standards question link . By accessing this link , IPs can ask a certified infection preventionist a question and have it answered . It will not result in notification of a surveyor or have any impact on the survey ( other than helping clarify a requirement ). IPs can ask for an email or a phone response . For complex questions , ask to schedule a phone call . If you feel that you need the answer in writing , ask if you can summarize the key points that you heard and send it to the to confirm or clarify the discussion .
Most IPs are responsible for ensuring organizational compliance to Joint Commission infection prevention and control standards . By following the aforementioned “ tips ” they can help ensure their healthcare organization is compliant with Joint Commission standards . The Joint Commission would love to hear from IPs . Submit suggestions for additional useful information , send feedback or ask a question though the Joint Commission ’ s
“ Ask a Standards Question ” link .
Sylvia Garcia Houchins , MBA , RN , CIC , is the director of infection prevention for the Joint Commission .