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PHC 6314, Unit 3: “Compliance-Accrediting & Regulatory Agencies; Policies &

Procedures, Part 1 of 2”

-TJC

-OSHA

-Policies

-Procedures

Welcome to Unit 3 entitled “Accrediting and Regulatory Agencies” and “Writing Policies & Procedures”. This unit consists of 2 parts. We will cover accrediting and regulatory agencies, such as the Joint Commission (TJC) and the Occupational Safety and Health Administration (OSHA); how to prepare for and participate in an inspection; and information on writing policies and procedures. This is Part I, which focuses on TJC Standards for Infection Prevention and Control.

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The Joint Commission

• The Joint Commission (TJC) (formerly known as JCAHO)

• Voluntary process

• Continuous accreditation cycle

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https://upload.wikimedia.org/wikipedia/en/f/f8/Joint_Commission.jpg

Let’s start with the Joint Commission (TJC), formerly known as the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). TJC accreditation is a voluntary process. A hospital does not have to be Joint Commission accredited. If your facility decides to be JC accredited and go through the process, then it has to abide by their standards. The Joint Commission accreditation cycle is continuous. An organization can have an unannounced survey between 18 and 39 months after its previous full survey. The current process is very different than how it has been in past years. As a result, the infection preventionist needs to ensure the healthcare facility is ready at all times for an inspection.

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TJC

• Mission of TJC is to continuously improve health care for the public

• By evaluating healthcare organizations & inspiring them to excel in providing safe & effective care of the highest quality & value

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The mission of Joint Commission is to continuously improve health care for the public, in collaboration with other stakeholders, by evaluating health care organizations and inspiring them to excel in providing safe and effective care of the highest quality and value. It is important to point out that TJC does not just survey hospitals but other types of healthcare facilities as well. TJC has different standards for each type of facility they survey.

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TJC I.C. Standards

• Infection Prevention & Control Standards

• Goal: To reduce the risk of acquisition & transmission of healthcare-associated infections (HAIs)

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We are going to be focusing on Joint Commission’s Infection Prevention and Control Standards specifically for acute care hospitals. The goal of the Infection Prevention and Control Standard is to reduce the acquisition of or further transmission of a healthcare-associated infection (HAI). The term for an infection acquired in a hospital used to be “nosocomial infection” for many years. Now it is being referred to as a healthcare-associated infection with the acronym “HAI”. Effective infection prevention and control requires an integrated, responsive process involving collaboration by many programs, services and settings throughout the hospital to develop, implement and evaluate the infection prevention and control (IC) program. The design and scope of the IC program are based on the risk that the hospital faces related to the acquisition and transmission of infectious disease.

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Format of Standards

• Number & description of standard• Elements of Performance (EP) (how

facility is evaluated to determine if meeting the standard)

• Rationale (for some)

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Each standard has a number and starts with a description of that particular standard, followed by a listing of elements of performance. Those are designated as EP. That designation of EP has to do with how that facility is evaluated to determine if they are meeting that standard. Some of the JC standards also include a rationale or justification, for why that particular item is a standard. In the case of the most current infection prevention and control standards at the time of this recording, two of them provide a rationale.

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I.C. Supported by Other Departments

• Environment of Care

• Human Resources

• Information Management

• Leadership

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Only going to cover Infection Prevention

& ControlStandards

There are some other standards in other parts of the accreditation manual that are related to infection prevention and control. These include the Environment of Care, Human Resources, Information Management, and Leadership. Human Resources, for example, would focus on ensuring that the healthcare workers who are working in the facility are credentialed and have current licenses. They’ll specifically look at the Infection Preventionists and the Hospital Epidemiologist to examine their credentials. Another way they might use Human Resources is to look at some healthcare workers’ records and see if they received education on infection control, did they get other required education; and, they also might check if employees received tuberculosis skin tests on a yearly or semi-annual basis. They might also look at if they were offered the Hepatitis B vaccine; and, if they declined, is there a declination form? Leadership standards would specifically examine how the Infection Control Program is managed at the highest level. For purposes of this lecture, we are only going to focus on the infection prevention and control standards. We will now proceed by going through the standards, listing the elements of performance, the rationale when applicable, and providing examples elements of performance (EP), for each standard. This is really critical for an Infection Preventionist to know in daily practice. It is a challenge to cover this material because Joint Commission is always updating their standards. There is more of a broad-based coverage of this material on the Certification Exam in Infection Control.

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IC.01.01.01

• The hospital identifies the individual(s) responsible for the infection prevention & control program

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Let’s start with the first standard, Infection Control IC.01.01.01. It

states, “The hospital identifies the individual(s) responsible for the infection prevention & control program”.

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IC.01.01.01Elements of Performance

(EP)(4)

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There are 4 Elements of Performance or EP for this first standard. The first EP is, “The hospital identifies the individual(s) with clinical authority over the infection prevention & control program”. The second is, “When the individual(s) with clinical authority over the infection prevention and control program does not have expertise in infection prevention and control, he or she consults with someone who has such expertise in order to make knowledgeable decisions.” The third is, “The hospital assigns responsibility for the daily management of infection prevention and control activities.” NOTE: The number and skill mix of the individual(s) assigned should be determined by the goals and objectives of the infection prevention and control program. The

fourth EP states, “For hospitals that use Joint Commission Accreditation for deemed status purposes: The individual with clinical authority over the infection prevention and control program is responsible for the following:

•Developing policies governing control of infections and communicable diseases

•Implementing policies governing control of infections and communicable diseases

•Developing a system for identifying, reporting, investigating, and controlling infections and communicable diseases.”

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Qualifications

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• Certification of IP’s

• Credentials for Hospital Epidemiologists

– Adult

– Pediatric

– Hospital Epidemiology courses

Let’s discuss qualifications in relation to infection prevention & control. One example of a qualification, is certification of Infection Preventionists (or IPs). This is attained every 5 years by an exam administered by the Certification Board of Infection Control (or CBIC), with successful completion of the exam allowing the designation C.I.C. (Certification in Infection Control) to be added to one’s credentials. For Hospital Epidemiologists, who usually have an M.D. or a Ph.D., TJC wants to see that such personnel are credentialed or board certified in adult medicine, infectious diseases, or pediatric medicine (for example), have taken hospital epidemiology courses, or perhaps have taken the Society for Healthcare Epidemiology (SHEA) “Introduction to Infection Control for Hospital Epidemiologists” course. SHEA has a course they offer several times a year for hospital epidemiologists. They have a little different training than infection preventionists; but require focused orientation to infection prevention & control.

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IC.01.02.01

• Hospital leaders allocate needed resources for the infection prevention & control program

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EP (3)

Standard IC.01.02.01 states, “Hospital leaders allocate needed

resources for the infection prevention and control program”. There are 3 Elements of Performance for this standard. The hospital provides: 1) access to information, 2) laboratory resources and 3) equipment and supplies, needed to support the infection prevention and control program.

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IC.01.02.01 Examples

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Personnel & Non-personnel Resources Necessary

This standard relates not only to personnel resources, such as a microbiologist or a statistician, but also to non-personnel resources like computers, software, and supplies. EP apply to having adequate systems to access information, laboratory support, equipment and supplies to support the IC program activities. If your laboratory cannot support your activities, then the hospital should contract with an outside laboratory. Equipment to carry out the surveillance for the program, and any supplies such as isolation signs that are needed or handouts for educating personnel, are examples of necessary supplies.

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IC.01.03.01

• The hospital identifies risks for acquiring & transmitting infections

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EP (5)

The third standard, IC.01.03.01 states, “The hospital identifies

risks for acquiring and transmitting infections.” There are 5 Elements of Performance for this standard. The hospital identifies risks for acquiring and transmitting infections based on the following: 1) the geographic location, community and population served, 2) the care, treatment, and services it provides, and 3) the analysis of surveillance activities and other infection control data, 4) The hospital reviews and identifies its risks at least annually and whenever significant changes occur with input from, at a minimum, infection control personnel, medical staff, nursing, and leadership, and 5) The hospital prioritizes the identified risks for acquiring and transmitting infections. These prioritized risks are documented.

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IC.01.03.01 Examples

• Hospital’s risk of infection based several factors

• Risks prioritized & reviewed at least annually

• Review needs to be by multi-disciplinary group

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Different hospitals have different risks of infection; and these are based on numerous factors. First, where is the facility located? Is it located in an area that has a very low prevalence for tuberculosis; or, in one that has a very high number of cases of a particular disease or condition? Those would be different situations. What is the environment for the facility? Is there a potential for environmental contamination? Are there vector-borne diseases prevalent? What is the situation in the environment that contributes to the risk of different types of infections? What are the characteristics and behaviors of the population served? Do you have all paying patients? Do you have patients who don’t have insurance? Do you have a large number of immigrants? Do you have a large number of patients in one age group? Surveillance data also influence the risk identification. What services are provided? If you’re a hospital that has a Level One, Two, and Three nursery then obviously you’re going to get sicker babies than someone who only has one level of an intensive care unit for babies. Do you have a Burn Unit? Burn patients have a high risk of infection. Does the facility perform open-heart surgeries, trauma surgeries; or, does it refer these cases out? Obviously, you won’t have as high a number of infections in that area if you refer them out. Is it a transplant hospital? A transplant hospital has to have positive airflow and anterooms; it is one of the highest risk populations for aspergillosis. TJC wants to be able to come in and see that you’ve assessed these risks at least on an annual basis and involved multi-disciplinary review (IC, Hospital epidemiology, medicine, nursing, and leadership, as examples).

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IC.01.04.01• Based on the identified risks, the

hospital sets goals to minimize the possibility of transmitting infections

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EP (5)

See also National Patient

Safety Goal 07.01.01

re: hand hygiene

Standard IC.01.04.01 states, “Based on the identified risks, the

hospital sets goals to minimize the possibility of transmitting infections.” There are 5 Elements of Performance for this standard. The hospital’s written infection prevention and control goals include the following: 1) addressing its prioritized risks, 2) limiting unprotected exposure to pathogens, 3) limiting the transmission of infections associated with procedures, 4) limiting the transmission of infections associated with the use of medical devices, equipment, and supplies, and 5) improving compliance with hand hygiene guidelines.

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IC.01.04.01 Examples

• unprotected pathogens exposures

• risk of transmission from procedures, medical equipment & devices

• improving hand hygiene compliance

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https://upload.wikimedia.org/wikipedia/commons/thumb/c/cf/Cleaning_hands.jpg/640px-Cleaning_hands.jpg

For limiting unprotected pathogens exposures, healthcare workers (HCWs), visitors, & families need to follow established policies for isolation/precautions, including wearing appropriate personnel protective equipment (PPE). HCWs need to use precautions when handling sharps. Patients need to be protected from ill HCWs by appropriate policies for work restrictions on employees with infectious diseases. Minimizing the risk of transmission from procedures, equipment and devices can be accomplished by having good policies, using aseptic technique and sterile supplies when needed, having healthcare workers be trained in these procedures, and following best practice guidelines for good patient care. Improving compliance with hand hygiene translates to some kind of monitoring of hand hygiene, followed by interventions to improve it when needed.

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IC.01.05.01• The hospital has an infection

prevention & control plan

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EP (7)

Standard IC.01.05.01 states, “The hospital has an infection prevention and control plan.” There are 7 Elements of Performance for this standard. 1. When developing infection prevention and control activities, the hospital uses evidence-based national guidelines or, in the absence of such guidelines, expert consensus. 2. The hospital’s infection prevention and control plan includes a written description of the activities, including surveillance, to minimize, reduce, or eliminate the risk of infection. 3. The hospital’s infection prevention and control plan includes a written description of the process to evaluate the infection prevention and control plan. 4. There is no EP 4. 5. The hospital describes, in writing, the process for investigating outbreaks of infectious disease. 6. All hospital components and functions are integrated into infection prevention and control activities. 7. The hospital has a method for communicating responsibilities about preventing and controlling infection to licensed independent practitioners, staff, visitors, patients, and families. Information for visitors, patients, and families includes hand and respiratory hygiene practices. 8. The hospital identifies methods for reporting infection surveillance and control information to external organizations.

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IC.01.05.01 Examples

• Written description of plan, including how to evaluate it

• Policies & procedures

• Investigating outbreaks

• Communication systems

• Reporting systems

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Here are some examples of elements of performance for this standard. This is a complicated standard. TJC wants evidence of the infection prevention and control plan. It should be outlined in writing, including an evaluation method. There need to be hospital wide and department-specific policies and procedures, based on national standards such as CDC, APIC, & SHEA. If there is a disease outbreak, there needs to be a specific system in place for investigating it (e.g., that you’ve got an epidemic management plan). The way that the organization communicates within itself, with the community and with outside agencies is assessed. Reporting systems are assessed for compliance with communicable disease and other required reporting conditions (local, state, and federal). You can see that there are many different facets involved in a hospital’s infection prevention and control plan.

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IC.01.06.01

• The hospital prepares to respond to an influx of potentially infectious patients

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EP (6)

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This standard (IC.01.06.01) states, “The hospital prepares to

respond to an influx of potentially infectious patients”. This standard is influenced by the result of events that have happened (e.g., anthrax attacks of 2001, pandemic influenza of 2009, Ebola outbreak of 2014) and things that may yet happen (such as new infectious disease emergence).

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IC.01.06.01 EP & Examples

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• resource identification &communication

• detailed written plan

• whether to take patients & if so, be able to for extended periods

There are 6 EP for this standard. 1. The hospital identifies resources that can provide information about infections that could cause an influx of potentially infectious patients (NOTE: Resources may include local, state, and federal public health systems). It goes without saying that hospitals need to be

networked with others, the local health department and have links to federal agencies (such as the Centers for Disease Control and Prevention). 2. The hospital obtains current clinical and epidemiological information from its resources regarding new infections that could cause an influx of potentially infectious patients. (The same sources listed in #1 apply here, when there is a current or pending infectious situation that could result in a large number of patients entering the hospital). 3. The hospital has a method for communicating critical information to licensed independent practitioners and staff about emerging infections that could cause an influx of potentially infectious patients. 4. The hospital describes, in writing, how it will respond to an influx of potentially infectious patients. (NOTE: One acceptable response is to decide NOT to accept patients. This might be necessary if the hospital already has its isolation/precautions room full or if the census is full and there are no patients that could be transferred out without compromising their conditions). 5. If the hospital

decides to accept an influx of potentially infectious patients, then the hospital describes in writing its methods for managing these patients over an extended period of time. This is a very

important point. Some disaster plans are only for 2-3 days. With a situation like pandemic influenza, for example, it may be necessary to care for infectious patients over an extended period of time (e.g., months). If a hospital has such a plan, it needs to provide evidence in writing of how that influx of patients can be

cared for and the hospital kept running for several months. 6. When the hospital determines it is necessary, the hospital activates its response to an influx of potentially infectious patients. For the EP in this standard, hospitals should have a disaster drill for an influx of potentially infectious patients at regular intervals. This is a way of identifying ahead of time, any problem areas that need to be addressed.

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IC.02.01.01

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EP (11)

•The hospital implements its infection prevention & control plan

Standard IC.02.01.01 states, “The hospital implements its

infection prevention and control plan.” There are 11 EP for this standard, related to the goal of minimizing, reducing or eliminating the risk of infection. 1. The hospital implements its infection prevention and

control activities, including surveillance, to minimize, reduce, or eliminate the risk of infection.

2. The hospital uses Standard Precautions*, including the use of personal protective equipment, to reduce the risk of infection. (Note: Standard Precautions are infection prevention and control measures to protect against possible exposure to infectious agents. These precautions are general and applicable to all patients.)

3. The hospital implements transmission-based precautions* in response to the pathogens that are suspected or identified within the hospital’s service setting and community. (Note: Transmission-based precautions are infection prevention and control measures to protect against exposure to a suspected or identified pathogen. These precautions are specific and based on the way the pathogen is transmitted. Categories include Contact, Droplet, Airborne, or a combination of these precautions.)

4. The hospital investigates outbreaks of infectious disease. 5. The hospital minimizes the risk of infection when storing

and disposing of infectious waste. 6. The hospital implements its methods to communicate

responsibilities for preventing and controlling infection to licensed independent practitioners, staff, visitors, patients, and families. Information for visitors, patients, and families includes hand and respiratory hygiene practices. (Note: Information may have different forms of media, such as posters or pamphlets.)

7. The hospital reports infection surveillance, prevention, and control information to the appropriate staff within the hospital.

8. The hospital reports infection surveillance, prevention, and control information to local, state, and federal public health authorities in accordance with law and regulation.

9. When the hospital becomes aware that it transferred a patient who has an infection requiring monitoring, treatment, and/or isolation, it informs the receiving organization.

10. When the hospital becomes aware that it received a patient from another organization who has an infection requiring action, and the infection was not communicated by the referring organization, it informs the referring organization. (Note: Infections requiring action include those that require isolation and/or public health reporting or those that may aid in the referring organization's surveillance.)

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Important Points re: Infection Prevention & Control Plan

• Relationship to first week’s reference article

• Coverage in Infection Control Certificate/MPH Courses

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from IC.02.01.01 standard

It is important to first mention that many of the items listed in the previous slide relate back to the reference article from the first week of class. Even though written in 1998, many of the infrastructure and essential activities listed in that reference article are components of current infection prevention and control programs in hospitals and other healthcare facilities. The second point is that this current course outlines these program components. The other required courses in the Infection Control Certificate program cover surveillance and outbreak management (Disease Surveillance & Monitoring Course), microbiology of important infections (Microbiology for Healthcare Workers course), and topics including precautions, personal protective equipment, sterilization & disinfection (Infectious Disease Prevention Strategies Course). These are all areas listed in this standard IC.02.01.01.

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IC.02.02.01

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EP (5)

•The hospital reduces the risk of infections associated with medical devices, equipment, & supplies

Standard IC.02.02.01 states, “The hospital reduces the risk of

infections associated with medical devices, equipment, & supplies.” There are 5 Elements of Performance for this standard.

The hospital implements infection prevention and control activities when doing the following: 1) cleaning and performing low-level disinfection, 2) performing intermediate and high-level disinfection and sterilization, 3) disposing of, and 4) storing medical equipment, devices and supplies, 5) when reprocessing single-use devices, the hospital implements infection prevention and control activities that are consistent with regulatory and professional standards.

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IC.02.02.01. Rationale

• Proper cleaning, disinfecting & sterilizing of medical equipment & supplies can reduce the risk of infection.

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https://upload.wikimedia.org/wikipedia/commons/3/37/2540EAP-B-L.jpg

Tabletop sterilizer

This standard has a rationale. The Centers for Disease Control and Prevention (CDC) estimate that 46.5 million surgical procedures are performed in hospitals and ambulatory settings each year; this includes approximately 5 million gastrointestinal endoscopies. Each of these procedures involves contact with a medical device or surgical instrument. A major risk of all such procedures is the introduction of pathogens that can lead to infection. Additionally, many more people are at risk of developing an infection from contact with medical equipment, devices, or supplies while seeking other health services. Failure to properly clean, disinfect, or sterilize, and use of or storage of medical equipment, devices, and supplies, not only poses risks for the person seeking health services, but also carries the risk for person-to-person transmission of infections.

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IC.02.02.01Examples of EP

• policies & procedures

• mechanisms for recall of improperly sterilized items

• mechanisms for identifying recalled items

• re-use issues

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There are numerous devices, types of equipment and supplies used in hospitals. There must be policies and procedures for how these items are cleaned, disinfected and sterilized. There must also be a policy for recalling instruments or devices that have been improperly sterilized, e.g., an implantable device. Items that are disposable must be disposed of according to laws and regulations. For example, used needles must go into approved sharps containers and then be incinerated. With the extensive amounts of medical devices, equipment and supplies, it is inevitable that there be recalls of contaminated or dangerous items. The hospital must have a mechanism for receiving information about such items, as well as mechanisms for removing recalled items from hospital circulation. The “Health

Devices Alert” is an informational bulletin publication that comes out weekly with items that need to be recalled, including food and medications, as well as equipment and supplies. For devices designed as single-use items, if hospitals re-use such items, it must be in accordance with existing regulations. Failure to do so might result in adverse events in a patient as well as liability for the hospital.

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IC.02.03.01

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EP (4)

•The hospital works to prevent the transmission of infectious disease among patients, licensed independent practitioners & staff

https://upload.wikimedia.org/wikipedia/commons/8/8e/TB_poster.jpg

Standard IC.02.03.01 states, “The hospital works to prevent the

transmission of infectious disease among patients, licensed independent practitioners & staff.” There are 4 Elements of Performance for this standard. 1. The hospital makes screening for exposure and/or immunity to infectious disease available to licensed independent practitioners and staff who may come in contact with infections at the workplace. 2. When licensed independent practitioners or staff have, or are suspected of having, an infectious disease that puts others at risk, the hospital provides them with or refers them for assessment, testing, immunization, prophylaxis/treatment, or counseling. 3. When licensed independent practitioners or staff have been occupationally exposed to an infectious disease, the hospital provides them with or refers them for assessment and potential testing, prophylaxis/treatment, or counseling. 4. When patients have been exposed to an infectious disease, the hospital provides them with or refers them for assessment and potential testing, prophylaxis/treatment, or counseling.

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This standard is related to Patient Safety and Employee Health. This standard can be summed up by stating that patients and employees should be protected from infections but if such infections should occur, they should be notified, treated and followed up. For a patient example, a chickenpox (or varicella) exposure to a patient from a staff member or family member might occur. The patient might need to receive treatment or post-exposure prophylaxis, with either the varicella vaccine or varicella immune globulin, and might need to be placed in isolation if in the hospital. The employee with chickenpox will be put off work or be given work restrictions, depending upon where they are in the infectious process and the policies of the hospital. For an employee example, a needlestick injury might result in the need for first aid, counseling, treatment with post-exposure prophylaxis for hepatitis B or HIV, and follow-up blood testing.

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IC.02.04.01

• The hospital offers vaccination against influenza to licensed independent practitioners & staff.

• Rationale

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EP (9)https://upload.wikimedia.org/wikipedia/commons/b/bb/Fluzone.jpg

Standard IC.02.04.01 states, “The hospital offers vaccination

against influenza to staff & licensed independent practitioners.” There are 9 EP for this standard. 1. The hospital establishes an annual influenza vaccination program that is offered to licensed independent practitioners and staff. 2. The hospital educates licensed independent practitioners and staff about, at a minimum, the influenza vaccine; non-vaccine control and prevention measures; and the diagnosis, transmission, and impact of influenza. 3. The hospital provides influenza vaccination at sites and times accessible to licensed independent practitioners and staff. 4. The hospital includes in its infection control plan the goal

of improving influenza vaccination rates. 5. The hospital sets incremental influenza vaccination goals, consistent with achieving the 90% rate established in the national influenza initiatives for 2020. 6. The hospital has a written description of the methodology used to determine influenza vaccination rates. 7. The hospital evaluates the reasons given by staff and licensed independent practitioners for declining the influenza vaccination. This evaluation occurs at least annually. 8. The organization improves its vaccination rates according to its established goals at least annually. 9. The organization provides influenza vaccination rate data to key stakeholders which may include leaders, licensed independent practitioners, nursing staff, and other staff at least annually. The rationale for this standard is provided: Patient safety is

improved when staff and licensed independent practitioners receive the influenza vaccination annually. According to the U.S. Department of Health and Human Services, vaccination remains the single most effective preventive measure against influenza, and it can prevent many illnesses, deaths and losses in productivity. Unvaccinated individuals who become infectious are contagious at least one day before any signs or symptoms of influenza appear, and therefore these individuals can infect others without knowing they are contagious. The Joint Commission has revised this standard and strengthened it to better reflect current science and national focus on influenza vaccination. It requires that each organization has an influenza vaccination program and that the influenza vaccination is offered to staff and licensed independent practitioners. However, The Joint Commission does not mandate influenza vaccination for licensed independent practitioners and staff as a condition of Joint Commission accreditation. Additionally, The Joint Commission does not require accredited organizations to pay for the influenza vaccination for its licensed independent practitioners and staff. The decision on whether to pay for the influenza vaccination for staff and licensed independent practitioners will need to be made independently by each accredited organization.

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IC.02.04.01 EP Examples

• Accessible sites

• Identifying reasons for poor vaccination

• Working to improve poor vaccination rates

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http://www.cdc.gov/flu/images/freeresources/whoneedsvaccine_red_250x300.jpg

One obstacle to effective vaccination is declination by healthcare personnel, which may be for several reasons. They may have been vaccinated elsewhere, have a medical contraindication, or have other personal reasons. Vaccination may also be declined because it is offered at inconvenient times or locations. Whatever the reasons, it is important for organizations to identify why individuals do not participate in the vaccination program, work to overcome these reasons, and increase vaccination rates. Examples of sites accessible to vaccination may be a vehicle, drive-through vaccination sites, sites located on the way to the cafeteria, or bringing the vaccine directly to the units of the hospital. Poor vaccination rates among healthcare workers need to be improved. Establishing campaigns on an annual basis to promote healthcare worker immunization is a strategy that might improve vaccination rates. Thus, the EP for this standard focus on establishing an influenza vaccination program for staff and

independent practitioners that is offered and evaluated annually, is easy to access, and that offers enhancements to increase participation.

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IC.03.01.01

• The hospital evaluates the effectiveness of its infection prevention & control plan

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EP (6)

Standard IC .03.01.01 states, “The hospital evaluates the

effectiveness of its infection prevention & control plan.” There are 6 EP for this standard. 1. The hospital evaluates the effectiveness of its infection prevention and control plan annually and whenever risks significantly change. 2-4. The evaluation includes a review of the following: the infection prevention and control plan’s prioritized risks, goals, and implementation of the plan’s activities. 5. There is no EOP 5. 6. Findings from the evaluation are

communicated at least annually to the individuals or interdisciplinary group that manages the patient safety program. 7. The hospital uses the findings of its evaluation of the infection prevention and control plan when revising the plan. (NOTE: Notice the numbering of the EOPs: 1, 2, 3, 4, 6, 7 – 5, NO EOP.) Evaluation helps to identify effective activities & those which need to be changed to improve outcomes.

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Summary

• TJC mission

• TJC standards for Infection Prevention & Control

• Elements of performance, rationale & examples

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In Part 1, we have covered the mission of the Joint Commission. We have outlined the infection prevention and control standards. Finally, we have listed the Elements of Performance for the standards and provided pertinent hospital infection control examples. This concludes Unit 3, Part I. In Part II, we will discuss how to prepare for a Joint Commission inspection, the Occupational Safety & Health Administration (OSHA), and policies and procedures.