SDS Accreditation Update: Focus on underreported infection-related events
Panel to revamp standards for sentinel events
The Joint Commission on the Accreditation of Healthcare Organizations is targeting infection control as a key focus for revision of standards and enhancement of sentinel event reporting efforts.
The Joint Commission is addressing infection control in several ways, says Nancy Kupka, RN, MS, MPH, associate project director of the division of research and evaluation for the Joint Commission. The agency convened an expert advisory panel that met for the first time in February 2003 to begin evaluation of the infection control standards, she says.
All Joint Commission standards have been reformatted and reworded to include easier-to-understand language and examples as part of the new accreditation initiative. However, Kupka points out that comments from organizations in the field that reviewed the revisions demonstrated a need to include more information and expand the standards’ requirements for infection control.
Although the panel primary task will be to evaluate and revise the standards, panel members also will be instrumental in defining and clarifying the requirements for reporting sentinel events related to infections, says Kupka.
Because the panel has just begun meeting, it is too early to determine when revised standards, or definitions for sentinel event reports, will be complete, she says. "We will keep our accredited organizations updated on our progress through direct communications as well as information on the Joint Commission web site [www.jcaho.org]," she adds.
Another way Joint Commission is addressing the importance of infection control is the inclusion of the issue in the fixed performance areas for random unannounced surveys for hospitals in 2003. (For other topics for unannounced surveys, see box below.)
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Random unannounced survey topics identified In a random unannounced survey (RUS) by the Joint Commission on the Accreditation of Healthcare Organizations, surveyors review fixed and variable performance areas, along with the variable topics based upon the organization’s last survey report. The fixed performance areas that will be reviewed during RUSs in 2003 by the Joint Commission are as follows: Ambulatory care:
Hospitals:
Approximately 5% of organizations accredited by the Joint Commission undergo a RUS each year. Organizations surveyed by the Wilmette, IL-based Accreditation Association of Ambulatory Health Care do not undergo random surveys. |
The Centers for Disease Control and Prevention (CDC) in Atlanta estimates that nearly 2 million patients in the United States acquire an infection as a result of care in a hospital, surgery center, long-term care facility, clinic, or dialysis center, and that almost 90,000 of those patients die as a result of the infection. Despite these numbers, only 10 infection-related reports have been reviewed as a sentinel event reported to the Joint Commission on the Accreditation of Health Care since the sentinel event policy was implemented in 1996. (Editor’s note: A series of articles on unhealthy hospitals that appeared in the Chicago Tribune in fall 2002 raised questions about the effectiveness of Joint Commission efforts to track and monitor infections in health care organizations that are accredited by the agency.1)
In December 2002, the Joint Commission sent a letter to all accredited organizations to draw attention to reportable sentinel events for which there appear to be lower frequency of reports than expected. The letter referenced unanticipated deaths or permanent loss of function that appear to be related to nosocomial infections.
"We do believe that infection-related sentinel events are underreported to us, but we don’t believe the underreporting is due to malice or an attempt to cover up a situation," says Kupka.
"Infections are underreported as sentinel events because it is hard to determine if a very ill person succumbed to the infection or the illness," she says. "Patient safety is a priority for our accredited organizations, and infection control is an important element in patient safety," Kupka points out.
Reference
1. Berens MJ, Japsen B. Patients suffer as agency shields troubled hospitals: Clean bills of health are awarded despite deaths, infection outbreaks. Series: Tribune Investigation, Unhealthy hospitals: The inspectors. Chicago Tribune; Nov. 10, 2002.
The Joint Commission on the Accreditation of Healthcare Organizations is targeting infection control as a key focus for revision of standards and enhancement of sentinel event reporting efforts.
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