Joint Commission changes HAI survey standards and focus


Hospitals and health systems that have not caught up with the latest version of The Joint Commission's National Patient Safety Goals could run into trouble.

Key Points

Hospitals and health systems that have not caught up with the latest version of The Joint Commission's National Patient Safety Goals could run into trouble. Organizations are now being evaluated under new standards designed to reduce the risk of healthcare-associated infections.

Infection control

"Many of the infection control requirements that used to be implied are now specifically addressed," said Louise M. Kuhny, RN, MPH, MBA, CIC, senior associate director of standards interpretation for The Joint Commission.

The new HAI standards were rolled out in 2007 and 2008, said Kuhny during a Webinar sponsored by Pharmacy OneSource. The HAI focus and more rigorous survey standards are part of 2011 National Patient Safety Goal 7, which focuses on hand hygiene, multidrug-resistant organisms (MDRO), central line-associated bloodstream infections (CLABSI), and surgical site infections (SSI).

NPSG 7 also includes new standards for catheter-associated urinary tract infection (CAUTI). The new CAUTI standards go into effect in 2012, which leaves hospitals just 6 months to prepare.

Two pillars

The Joint Commission infection control standards are based on 2 pillars, Kuhny said. The first pillar is a customized infection program based on each organization's own risks at each location. The second pillar is adherence to relevant scientific guidelines and regulatory requirements.

"Each hospital is different and each risk assessment is different," said Kuhny. "We expect each of you to have a completely customized risk analysis program in place. Our surveyors focus on the relevant scientific guidelines. If you reference the guideline you are using in your infection control program, surveyors don't have to wonder why you are doing certain things and not doing other things."

Kuhny offered hand hygiene as an example. Hospitals can comply with either the current Centers for Disease Control and Prevention guidelines or the World Health Organization guidelines. Hospitals don't get to pick and choose sections from different guidelines to create their own program. Enhancements can be added, but basic hand-hygiene practices must follow either the most current CDC or WHO guidelines.

Greater emphasis on education

Surveys are taking on a more educational role, said Kuhny. In the past, surveyors typically used a 3 strikes rule. Three observed instances of noncompliance resulted in an automatic requirement for improvement. Current standards push surveyors to look beyond compliance and ask about goals, interventions, and improvements.

Institutions that can show specific goals and demonstrate measurable progress toward meeting those goals are more likely to receive encouragement and suggestions for continued improvement rather than a formal requirement for improvement.

The change in attitude is part of The Joint Commission's new role to help find solutions to healthcare problems, not just provide accreditation services, Kuhny said.

Details of standards for hand hygiene and other requirements are available at


Sections that deal with MDRO, CLABSI, and SSI follow a similar scheme. Joint Commission standards call for implementation of best practices or evidence-based guidelines to prevent each type of infection. CAUTI standards will follow the same pattern starting in 2012, Kuhny said.

MDRO may be the most confusing area, because it deals with multiple organisms, including methicillin-resistant Staphylococcus aureus, Clostridium difficile, vancomycin-resistant enterococci, and a multitude of drug-resistant gram-negative pathogens. It will be essential to show that the institution is implementing evidence-based practices to assess and reduce risks.

Surveyors are focusing on 8 key areas: staff education, education of patients and family members, use of an active surveillance program, monitoring and measurement of progress, communication with key stakeholders, use of evidence-based policies and procedures, use of a laboratory-based alert system, and tracking of readmissions that may represent increased risk.

"We expect you to keep up with current guidelines," Kuhny said. "You should be reading CDC's Morbidity and Mortality Weekly Report. My No. 1 tip is to read Perspectives, your primary source for all things regarding The Joint Commission. And when you are in doubt, ask. Healthcare-acquired infections are an area where you shouldn't guess."

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