JCAHO standards emphasize ICP expertise
The current infection control standards for hospitals as promulgated by the Joint Commission on Accreditation of Healthcare Organizations are summarized as follows:1
IC.1 The organization uses a coordinated process to reduce the risks of endemic and epidemic nosocomial infections in patients and health care workers.
IC.1.1 The infection control process is managed by one or more qualified individuals.
IC.2 Case findings and identification of demographically important nosocomial infections provide surveillance data.
IC.3 The hospital reports, when appropriate, information about infections both internally and to public health agencies.
IC.4 The hospital takes action to prevent or reduce the risk of nosocomial infections in patients, employees, and visitors.
IC.5 The hospital takes action to control outbreaks of nosocomial infections when they are identified.
IC.6 The hospital’s infection control process is designed to lower the risks and to improve the (proportional) rates or (numerical) trends of epidemiologically significant infections.
IC.6.1 Management systems support the infection control process.
IC.6.2 The infection control process includes at least one activity aimed at preventing the transmission of epidemiologically significant infections between patients and staff.
Examples of Evidence of Performance for IC.1
• Interview with staff, ICP, physician advisor, chair of ICC, and administration
• Document review of policies and procedures of the organization’s demographics and definitions of epidemiologically important issues
• Review of IC program description
• Review of scope of Employee Health Program
Example of Implementation for IC.1.1
An individual with training in infection surveillance, prevention, and control functions assumes the responsibility of managing those functions. This person also has knowledge of job experience in the areas of epidemiological principles and infectious disease, as well as sterilization, sanitation, and disinfection practices. This individual is also knowledgeable in adult education principles or patient care practice. Additionally, successful completion of a course in infection control and certification through the Certification Board of Infection Control (CBIC) may be a benchmark for competence in this area.
Examples of Evidence of Performance for IC.1.1
• Record(s) for training and continuing education
• Clinical privileges
• Job description
• Scope of responsibility statement in bylaws, rules, or regulations
Reference
1. The Joint Commission on Accreditation of Healthcare Organizations. 1997 Accreditation Manual for Hospitals. Oakbrook Terrace, IL; 1996.
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