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2005 JCAHO standards feature analysis, action
Some of the key aspects of the Joint Commission on Accreditation of Healthcare Organizations 2005 infection control standards are summarized here:
IC.1.10 Risk of Health Care-Associated Infections are Minimized Through an Organizationwide Program
• All applicable components are integrated.
• Everyone in organization is knowledgeable.
• Infections are reported.
• Outbreaks are investigated.
• Written plan exists that includes:
— goals of program;
— prioritize risks;
— strategies to handle risks;
— evaluation of success.
IC.2.10 Identify Risks of Acquisition and Transmission on an Ongoing Basis
• Risks are identified proactively and retrospectively.
• Formal review of analysis is held at least annually.
• Surveillance activities are targeted.
IC.3.10 — Based on Risk, Priorities and Goals are Set to Prevent Infections
• Priorities and goals are established.
• Hand hygiene is enhanced.
• Risk of transmission with procedures, equipment, and devices is minimized.
IC.4.10 — Strategies Implemented to Achieve Goals
• Relevant guidelines are incorporated.
• Risks associated with procedures, medical equipment, and devices are reduced.
• Applicable precautions are used.
• Screening and intervention of people in facility is practiced.
IC.5.10 — Evaluation of Effectiveness of Intervention and Redesign
• Program’s goals are evaluated and revised.
• Emerging problems in health care community are addressed.
• Relevant guidelines are evaluated.
IC.7.10 — Program Managed Effectively
• Responsibility to manage program is assigned.
• Qualification is determined by program’s needs.
• Individual(s) coordinate all parts of program.
• Individual(s) facilitate monitoring of effectiveness.
IC.8.10 — Representatives from Components Collaborate to Direct Implementation
• Leaders collaborate with IC program managers.
• They assess adequacy of resources.
• They assess outcomes of goals.
• They revise program to improve outcomes.
IC.9.10 Leaders Allocate Adequate Resources
• report of effectiveness to Patient Safety Program;
• sufficient staff (numbers, competence, skill mix);
• adequate information systems;
• adequate laboratory support;
• adequate equipment and supply.