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.