must ensure EBGs are used to clarify additional requirements and not to supersede the IFU .
If an EBG is not required , how can infection preventionists assess whether it should be incorporated into their infection control program ?
It is essential for infection preventionists to pay careful attention to sources and processes used to develop recommended infection control practices . They should know the difference between an EBG , guidance , consensus documents , position statements and policies , as well as the processes used to develop these documents so they can make educated choices .
● EBGs : Developed to answer questions via a literature search protocol which identifies relevant articles . The evidence in those articles is then abstracted and summarized before a group assesses it and formulates recommendations based on consensus . Before approval and publication , factors assessed include impact , feasibility , and risk and benefits . EBGs should provide references for the user to evaluate relevance and context specifically for their HCO .
● Guidance : Meant to provide instruction on how to address a situation and may include relevant literature . However , guidance documents may not consider unique aspects of each HCO and must be carefully evaluated to determine risk and benefits to HCOs that follow the guidance .
● Consensus documents : Created by a group and represent those individuals ’ collective opinions , which may or may not be supported by scientific literature . If a consensus group follows the American National Standards Institute ( ANSI ) and agrees to its oversight , procedures , approval process and more , their resulting consensus document becomes an American National Standard . ISO standards are an example of consensus documents developed through the consensus of experts from many countries and approved and published by a globally recognized body . Infection preventionists may need to review literature to ensure it supports recommendations made in consensus documents .
● Position statements : Provide viewpoints of a professional organization on a particular topic , as well as background and rationale to support that viewpoint . Infection preventionists may need to do their own literature review to determine if the viewpoint is sound or could be negated by additional information .
● Policies : Represent both how an HCO interprets relevant requirements and how it implements them .
Misinterpreting EBGs , guidance , consensus documents and position statements as requirements and adopting policies of other organizations with differing requirements , especially across state lines , has led to significant misunderstandings regarding Joint Commission and CMS requirements . Such misinterpretations can result in regulatory , financial and resource implications for HCOs Infection Preventionists must clearly articulate to surveyors which EBGs are required within their state or manufacture instructions and which EBGs or other documents have been incorporated by choice .
Which part of an EBG is required by The Joint Commission ?
Unless required by Joint Commission standards , regulation or manufacturer instructions , HCOs may choose which segments of EBGs and consensus documents to incorporate into their practices . To help identify the appropriate recommendations to use , HCOs should consider level of recommendation or word choice , for instance :
● CDC ( use of rankings ): 1A and 1B recommended , 1C required , and II suggested
● AORN ( use of a word within context of the guidelines ): Should indicates action is recommended ; must describes requirements mandated by regulation ; may indicates action is permissible within the limits of the guideline ; and can indicates possibility and capability .
● Association for the Advancement of Medical Instrumentation ( AAMI ) ( use of verbal terms within documents to distinguish its requirements ): Shall and shall not express requirements ; should and should not express recommendations ; may and may not express permission ; can and cannot as statements of possibility or capability ; might and might not express possibility ; and must signifies external constraints or obligations defined outside the document .
It is important to review rankings and terms provided by authors seek clarity of a perceived requirement from the authoring organization .
Infection preventionists need to clearly understand when , which and what part of EBGs are required before selecting a particular EBG or another document to incorporate into their infection control policies , protocols or processes . They should add recommendations above the basic requirements from EBGs to organizational requirements only if they are based on compelling evidence that the improve safety or quality , are feasible , and cost effective . Requirements based of optional EBGs should never be added if they conflict with routine organizational practices .
An ideal EBG process is one that includes multidisciplinary input and evaluation of EBGs and other documents before they are incorporated into policies . Since leadership is responsible for the development and implementation of organizational policies , there should be a process to ensure leadership agrees with the incorporation of optional EBGs . This helps an HCO avoid being scored for non-compliance during survey and allows it to explain which and what part of EBGs have been incorporated into its infection control program .
Sylvia Garcia-Houchins , MBA , RN , CIC , is director of infection prevention and control for The Joint Commission .
References :
1 . The Joint Commission . Clarifying Infection Control Policy Requirements . Perspectives . April 2019 .
2 . Illinois Administrative Code . Title 77 § 300.696 available at Section 300.696 - Infection Prevention and Control , Ill . Admin . Code tit . 77 § 300.696 | Casetext Search + Citator Accessed February 25 , 2023