Accreditation Program: Hospital

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1 ccreditation Program: Hospital Infection Prevention and ontrol 2008 The Joint ommission on ccreditation of Healthcare Organizations

2 ccreditation Program: Hospital hapter: Infection Prevention and ontrol Standard I.0001 The [organization] identifies the individual(s) responsible for the infection prevention and control program. Elements of Performance for I.0001 The hospital identifies the individual(s) with clinical authority over the infection prevention and control program. 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. (See also I.0001, EP 1) The hospital assigns responsibility for the daily management of infection prevention and control activities. (See also HR.0001, EP 1; LD.0001, EP 3) Note: Number and skill mix of the individual(s) assigned should be determined by the goals and objectives of the infection prevention and control program. Standard I.0001 Hospital leaders allocate needed resources for the infection prevention and control program. Elements of Performance for I.0001 The hospital provides access to information needed to support the infection prevention and control program. (See also I.0001, EP 2; I.0001, EP 3; I.0001, EPs 1 and 2; I , EP 2; I.0001, EP 8; I.0001, EP 1; IM.0003, EP 2) The hospital provides laboratory resources when needed to support the infection prevention and control program. (See also I.0001, EP 2) The hospital provides equipment and supplies to support the infection prevention and control program. (See also I.0001, EP 2; I.0001, EPs 2 and 3; LD.0001, EP 4) Page 2 of The Joint ommission on ccreditation of Healthcare Organizations

3 ccreditation Program: Hospital hapter: Infection Prevention and ontrol Standard I.0001 The [organization] identifies risks for acquiring and transmitting infections. Elements of Performance for I.0001 The hospital identifies risks for acquiring and transmitting infections based on the following: Its geographic location, community, and population served. The hospital identifies risks for acquiring and transmitting infections based on the following: The care, treatment, and services it provides. The hospital identifies risks for acquiring and transmitting infections based on the following: The analysis of surveillance activities and other infection control data. (See also I.0001, EP 1; TS.0001, EP 2) 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. (See also I.0001, EP 1) The hospital prioritizes the identified risks for acquiring and transmitting infections. These prioritized risks are documented. (See also I.0001, EP 1; I.0001, EP 2; I.0001, EP 2) Standard I.0001 Based on the identified risks, the [organization] sets goals to minimize the possibility of transmitting infections. Elements of Performance for I.0001 The hospital's written infection prevention and control goals include the following: ddressing its prioritized risks. (See also I.0001, EP 5; I.0001, EP 3) The hospital's written infection prevention and control goals include the following: Limiting unprotected exposure to pathogens. (See also I.0001, EPs 2 and 3; I.0001, EP 3) The hospital's written infection prevention and control goals include the following: Limiting the transmission of infections associated with procedures. (See also I.0001, EP 3) The hospital's written infection prevention and control goals include the following: Limiting the transmission of infections associated with the use of medical equipment, devices, and supplies. (See also I.0001, EPs 1-5; I.0001, EP 3) The hospital's written infection prevention and control goals include the following: Improving compliance with hand hygiene guidelines. (See also I.0001, EP 3; NPSG , EP 1) Page 3 of The Joint ommission on ccreditation of Healthcare Organizations

4 ccreditation Program: Hospital hapter: Infection Prevention and ontrol Standard I.0001 The [organization] has an infection prevention and control plan Elements of Performance for I.0001 When developing infection prevention and control activities, the hospital uses evidence-based national guidelines or, in the absence of such guidelines, expert consensus. (See also I.0001, EP 1) 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. (See also I.0001, EPs 1-3; I.0001, EP 5; I.0001, EP 1; I.0001, EP 4) The hospital s infection prevention and control plan includes a written description of the process to evaluate the infection prevention and control plan. (See also I.0001, EP 1) The hospital describes, in writing, the process for investigating outbreaks of infectious disease. (See also I.0001, EP 5) ll hospital components and functions are integrated into infection prevention and control activities. (See also HR.0001, EPs 2 and 4) The hospital has a method for communicating responsibilities about preventing and controlling infection to licensed independent practitioners, staff, visitors, patients, and families. (See also I.0001, EP 7) The hospital identifies methods for reporting infection surveillance and control information to external organizations. (See also I.0001, EPs 9-11) Page 4 of The Joint ommission on ccreditation of Healthcare Organizations

5 ccreditation Program: Hospital hapter: Infection Prevention and ontrol Standard I The [organization] prepares to respond to an influx of potentially infectious [patient]s. 6. Elements of Performance for I 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. The hospital obtains current clinical and epidemiological information from its resources regarding new infections that could cause an influx of potentially infectious patients. (See also I.0001, EP 1) 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. The hospital describes, in writing, how it will respond to an influx of potentially infectious patients. (See also EM.0001, EP 2) Note: One acceptable response is to decide not to accept patients. 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. When the hospital determines it is necessary, the hospital activates its response to an influx of potentially infectious patients. Page 5 of The Joint ommission on ccreditation of Healthcare Organizations

6 ccreditation Program: Hospital hapter: Infection Prevention and ontrol Standard I.0001 The [organization] implements its infection prevention and control plan Elements of Performance for I.0001 The hospital implements its infection prevention and control activities, including surveillance, to minimize, reduce, or eliminate the risk of infection. (See also I.0001, EP 2) The hospital uses standard precautions, including the use of personal protective equipment, to reduce the risk of infection. (See also I.0001, EP 3) 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. Footnote: For further information regarding standard precautions, refer to the Web site of the enters for Disease ontrol and Prevention (D) at The hospital implements transmission-based precautions in response to the pathogens that are suspected or identified within the hospital s service setting and community. (See also I.0001, EP 3) 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. ategories include contact, droplet, airborne, or a combination of these precautions. Footnote: For further information regarding transmission-based precautions, refer to the Web site of the enters for Disease ontrol and Prevention (D) at The hospital investigates outbreaks of infectious disease. (See also I.0001, EP 5) The hospital minimizes the risk of infection when storing and disposing of infectious waste. (See also E.0001, EP 1) The hospital implements its methods to communicate responsibilities for preventing and controlling infection to licensed independent practitioners, staff, visitors, patients, and families. (See also I.0001, EP 7; HR.0001, EP 4) The hospital reports infection surveillance, prevention, and control information to the appropriate staff within the hospital. (See also I.0001, EP 6) The hospital reports infection surveillance, prevention, and control information to local, state, and federal public health authorities in accordance with law and regulation. (See also I.0001, EP 8) 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. (See also I.0001, EP 8) Page 6 of The Joint ommission on ccreditation of Healthcare Organizations

7 1 ccreditation Program: Hospital hapter: Infection Prevention and ontrol 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. (See also I.0001, EP 8) 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. Standard I.0001 The [organization] reduces the risk of infections associated with medical equipment, devices, and supplies. Elements of Performance for I.0001 The hospital implements infection prevention and control activities when doing the following: leaning and disinfecting medical equipment, devices, and supplies. The hospital implements infection prevention and control activities when doing the following: Sterilizing medical equipment, devices, and supplies. (See also E.0003, EP 4) The hospital implements infection prevention and control activities when doing the following: Disposing of medical equipment, devices, and supplies. The hospital implements infection prevention and control activities when doing the following: Storing medical equipment, devices, and supplies. When reprocessing single-use devices, the hospital implements infection prevention and control activities that are consistent with regulatory and professional standards. Standard I.0001 The [organization] works to prevent the transmission of infectious disease among [patient]s, licensed independent practitioners, and staff. Elements of Performance for I.0001 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. 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. When licensed independent practitioners or staff have been occupationally exposed to an infectious disease, the hospital provides them with or refers them for assessment, testing, immunization, prophylaxis/treatment, or counseling. When patients have been exposed to an infectious disease, the hospital provides them with or refers them for assessment, testing, immunization, prophylaxis/treatment, or counseling. Page 7 of The Joint ommission on ccreditation of Healthcare Organizations

8 ccreditation Program: Hospital hapter: Infection Prevention and ontrol Standard I.0001 The [organization] offers vaccination against influenza to licensed independent practitioners and staff. Elements of Performance for I.0001 The hospital establishes an annual influenza vaccination program that is offered to licensed independent practitioners and staff. 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. (See also HR.0001, EP 4) The hospital provides influenza vaccination at sites accessible to licensed independent practitioners and staff. The hospital annually evaluates vaccination rates and the reasons given for declining the influenza vaccination. The hospital takes steps to increase influenza vaccination rates. Standard I.0001 The [organization] evaluates the effectiveness of its infection prevention and control plan Elements of Performance for I.0001 The hospital evaluates the effectiveness of its infection prevention and control plan annually and whenever risks significantly change. (See also I.0001, EP 1; I.0001, EP 4; I.0001, EP 3) The evaluation includes a review of the following: The infection prevention and control plan's prioritized risks. (See also I.0001, EP 5) The evaluation includes a review of the following: The infection prevention and control plan's goals. (See also I.0001, EPs 1-5) The evaluation includes a review of the following: Implementation of the infection prevention and control plan s activities. (See also I.0001, EP 2; I.0001 through I.0001) Findings from the evaluation are communicated at least annually to the individuals or interdisciplinary group that manages the patient safety program. (See also I.0001, EP 9; LD.0001, EP 5) The hospital uses the findings of its evaluation of the infection prevention and control plan when revising the plan. (See also I.0001 through I.0001) Page 8 of The Joint ommission on ccreditation of Healthcare Organizations

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