JCAHO 2005 Infection Control Program Principal Components
Important evidence-based interventions to decrease morbidity, mortality and health care
cost for the industry have been elaborated in the effort to prevent Health
Care-Associated Infections (HAIs). The Joint Commission
is addressing infection control issues through several initiatives for the health industry for critical care areas, such as such
as Hospital, Long Term Care, Home Care, Behavioral Health Care and Ambulatory Care organizations.The preliminary standards and their elements of performance for year 2005 for hospitals have been published recently by JCAHO in its website and will become effective January 1, 2005.
HOSPITAL 2005. Preliminary Control of Infection Standards
Prevention of health care-associated
infections (HAIs) represents one of the major safety initiatives an organization can undertake, making the effective evaluation
and possible redesign of existing infection prevention and control programs (hereafter referred to as the “IC program”)
a priority. The CDC estimates that each year, approximately
2 million patients admitted to acute care hospitals in the United States acquire infections that were not related to
the condition for which they were hospitalized 1. These infections result in approximately 90,000 deaths/year,
and add between $4.5 to $5.7 billion per year to patient care costs (CDC, 1992) 2.
Although some causes of HAIs
are difficult to control, such as underlying diseases, many high risk behaviors and situations, and some direct causes of HAIs have been identified
and can be controlled. Approximately one third of HAIs could be prevented using appropriate recommendations3,4
, according to data recollected in publications of the last twenty years.
JCAHO IC Perspective
for Hospitals
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 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. The goal of an effective IC program
is to reduce the risk of acquisition and transmission of HAIs.
Hospitals must do the following
to prevent HAIs5:
- The hospital incorporates
its infection control program as a major component of its safety and performance improvement programs.
- The hospital performs an
ongoing assessment to identify its risks for the acquisition and transmission of infectious agents.
- The hospital uses an epidemiological
approach that consists of:
· surveillance
· data collection
· trend identification
- The hospital effectively
implements infection prevention and control processes.
- The hospital educates
and collaborates with organizationwide leaders to effectively participate in the design and implementation
of the IC program.
- The hospital integrates its
efforts with health care and community leaders to the extent practicable, recognizing that infection prevention and
control is a communitywide effort.
- To remain a viable community
resource, the hospital must plan for responding to infections that potentially overwhelm its resources.
A program with aims of such broad scope and depth requires the direct involvement
of hospital leaders. Only with the ongoing attention and direction of hospital leadership can the appropriate scope of the
IC program be determined and adequately resourced.
The standards in this chapter, which focus on development and implementation
of plans to prevent and control infections, are supported by standards in other chapters, such as Management of the Environment
of Care, Management of Human Resources, Improving Organization Performance, and Leadership, to produce a comprehensive approach
to IC.
The Infection Control Program and Components
IC.1.10 The risk of development of a health care-associated infection (HAI) is minimized through
an organization-wide infection control program.
IC.2.10 The infection control program identifies risks for the acquisition and transmission of
infectious agents on an ongoing basis.
IC.3.10 Based on risks, the hospital establishes priorities and sets goals for preventing the development
of health care-associated infections within the hospital.
IC.4.10 Once the hospital has prioritized its goals, strategies must be implemented to achieve
the goals.
IC.5.10 The infection control program evaluates the effectiveness of the infection control interventions
and, as necessary, redesigns the infection control interventions.
IC.6.10: On review. Please refer to Joint Commission Perspectives ® publication for more information about this standard
Structure and Resources
for the IC Program
IC.7.10 The infection control program is managed effectively.
IC.8.10 Representatives from relevant components/functions within the hospital collaborate to
implement the infection control program.
IC.9.10 Hospital
leaders allocate adequate resources for the infection control program.
General Sterile Processing
Compliance Check List
Check the whole sterile process
system compliance with standards.
- Review of policies
and procedures.
- Assessment
of recommended practice compliance ( AAMI 10 and AORN).
- Assessment
of OSHA standards compliance associated with sterile processing.
- Assessment
of JCAHO standards compliance.
- Observation
of work practices.
- Assessment
of performance improvement process.
- Assessment
of leadership functions.
- Analysis of
standard of patient care as it relates to processing methods.
- Review of management
of the environment of care (safety, waste management, and emergency preparedness procedures).
- Assessment
of management of human resources, including staffing ratios and staff development opportunities
- Assessment
of management of information in maintaining confidentiality and data integrity associated with sterile processing activities
Review of infection prevention processes as they relate to decontamination, sterilization, and sterility maintenance.
REFERENCES
1 Monitoring hospital-acquired infections to promote patient safety—United States, 1990-1999. MMWR Morb Mortal
Wkly Rep 49:149-153, Mar. 10, 2000.
2 Public Health focus: surveillance, prevention and control of nosocomial infections. MMWR Morb Mortal Wkly Rep 41:783-787,
Oct. 23, 1992.
3 Harbarth S., Sax H., Gastmeier P.: The preventable proportion of nosocomial infections: an overview of published reports.
J Hosp Infect 54:258–256, Aug. 2003.
4 Haley R.W., et al.: The efficacy of infection surveillance and control programs in preventing nosocomial infections
in US hospitals. Am J Epidemiol 121:182-205, Feb. 1985.
5. 2004 CAMH Update 1 Prepublication Copy ©JCAHO 2003 http://www.jcaho.org/accredited+organizations/patient+safety/infection+control/05_ic_std_hap.pdf/03
6. Dear Colleague Letter: Underreported Sentinel Events
7 Examples of guidelines include those offered by the CDC, Healthcare Infection Control Practices Advisory Committee
(HICPAC), and National Quality Forum (NQF).
8 Medical equipment Fixed and portable equipment used for the diagnosis, treatment, monitoring,
and direct care of Individuals
9. Steris. Clinical Preparation Services. www.steris.com
10. AAMI. Standards. http://www.aami.org/standards/index.html
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