Editor's note: Each installment of Joint Commission Standards will review a chapter of the Comprehensive Accreditation Manual for Hospitals and may be distributed to staff as a teaching tool. Joint Commission Standards will be updated monthly online and appear regularly in print.

The chapter, Surveillance, Prevention and Control of Infection (IC), focuses on the development and implementation of plans to prevent and control infection through an IC program integrated throughout the hospital. The chapter first addresses the IC program and its components, followed by standards that speak to program structure and resources.

New for 2007

IC.4.15 Immunization against influenza is offered to staff and licensed independent practitioners (LIP).

This standard is consistent with the CDC recommendation that all healthcare personnel be vaccinated annually. The Elements of Performance (EP) require that:

• at minimum the immunization program should include staff and LIP
• immunization access is provided on-site;
• education related to vaccination, non-vaccine prevention measures, and the diagnosis, transmission and potential impact of influenza is provided;
• evaluation of vaccination rates and reasons for non-participation occur annually; and
• program enhancements to improve participation are implemented.

Avoiding Common Pitfalls

IC.1.10 The risk of development of a healthcare-associated infection is minimized through a hospitalwide infection control program.

This standard has nine EPs related to the scope and implementation of an IC plan and program.

EP 4 addresses systems in place to communicate with LIP, staff, students, volunteers and, when appropriate, visitors, patients and families about infection control and prevention issues.

EP 5 speaks to systems for communicating results of surveillance, prevention and control information to appropriate staff within the hospital, public health authorities, transfer facilities, etc. The 2005 root-cause analysis of sentinel events found communication to be one factor in approximately 75 percent of infection-associated events.

Need to know:

• How do patients and families learn about basic infection control practices?
• Does the hospital participate in "Speak Up," a Joint Commission program to educate patients, families and visitors about preventing the transmission of infection?
• Over the past year, what education have you received related to prevention of healthcare-associated infection?
• How do you receive current information about your specific unit's healthcare-associated infection rates? Are the rates within benchmark? What is the plan if improvement is needed?
• If a patient is admitted and TB is being ruled out, what is your role in the internal reporting process? Who needs to know what?
• What precautions are taken when you transport a patient with an airborne disease to another area of the hospital? What information is given to the receiving department?

IC.3.10 Based on risks, the hospital establishes priorities and sets goals for preventing the development of healthcare-associated infections within the hospital.

This standard has four applicable EPs that speak to the rationale behind the infection prevention goals and priorities, the use of personal protective equipment throughout the hospital, improving handwashing techniques and compliance, and reducing the risk of transmitting infection associated with the use of medical equipment and devices.

Need to know:

What personal protection equipment is stored on your unit and where is it?
Who monitors compliance with the CDC guidelines for handwashing? What is the compliance rate?
What are the handwashing steps when wearing gloves?
How do you know if an IV pump or commode has been cleaned between patient use? Who cleans it and what is the process?
If cleaning/disinfectant solutions are used by staff on the unit, what are the manufacturer's instructions for product use?    

IC.6.10 As part of its emergency management activities, the hospital prepares to respond to an influx, or risk of an influx, of infectious patients.

The three EPs related to this standard deal with the hospital's planned response to a potential or actual epidemic.

Need to know:

• Where is the hospital's emergency management plan housed on your unit?
• What is your role when the emergency management plan is activated?

All healthcare personnel play a key role in the prevention of infection. The prevention of infection within the healthcare organization is viewed as part of basic care and falls under the principle of "do no harm."

The Joint Commission has identified the risks associated with nosocomial infection rates and looks critically at the infection control practices of an organization as part of the survey. Compared to some standards that require system processes for successful implementation, infection control is a standard that requires a well-informed staff who consistently carries out the principles to achieve success for the patient and the organization.

Jean Kalemba was previously director of performance improvement at Mountainside Hospital, Montclair, NJ. She is skilled in developing and implementing programs to meet hospital regulatory agency requirements and has an excellent record in preparing organizations for licensing and accreditation surveys.