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Infection preventionists should be aware that as part of its ongoing enforcement of patient safety goals, The Joint Commission will be assessing hand hygiene compliance during 2018 accreditation surveys.
“Beginning Jan. 1, 2018, any observation by surveyors of individual failure to perform hand hygiene in the process of direct patient care will be cited as a deficiency resulting in a Requirement for Improvement (RFI) under the Infection Prevention and Control (IC) chapter for all accreditation programs,” The Joint Commission recently announced.
The observations can be made at any point during the survey visit.
“Our surveyors are trained so that during our onsite surveys, they follow the care of the patient in conducting what we call an individual patient tracer,” says Mary Brockway, MS, RN, director of clinical research and standards in TJC Division of Healthcare Quality Evaluation.
“So that allows them to observe the clinical staff providing direct patient care throughout the survey. Patient care is fluid, but any failure to wash hands prior to providing care will be cited.”
However, surveyors are not likely to correct or question a healthcare worker not following hand hygiene protocols.
“We’re there to help organizations improve, and conducting the survey is part of that process,” she says. “We would not normally confront a healthcare worker about not washing their hands, but we may explore further with several workers about their handwashing programs. How is the access to sinks and soaps? Have they been educated? Those types of things. We would follow up with the organization to do this as we are doing the survey process.”
Those that receive an RFI citation may have the situation assessed again on a subsequent survey, Brockway says.
Financial Disclosure: Senior Writer Gary Evans, Editor Jesse Saffron, Editor Jill Drachenberg, Nurse Planner Patti Grant, RN, BSN, MS, CIC, Peer Reviewer Patrick Joseph, MD, and Editorial Group Manager Terrey L. Hatcher report no consultant, stockholder, speaker’s bureau, research, or other financial relationships with companies having ties to this field of study.
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