Stealth standards: Add engineer’s hat to the rack

Many unaware of Joint Commission changes

In accreditation changes that may have slipped beneath the radar of many infection control professionals, ICPs must now regularly collaborate with physical plant staff and ensure the safety of the hospital environment.

"An area of collaboration that significantly impacts infection control practice is the need to start working together with your engineers," said Patrice Spath, RHIT, an expert on complying
with the Joint Commission on Accreditation of Healthcare Organizations. Infection control accreditation changes were the subject of a special teleconference recently held by American Health Consultants, publishers of Hospital Infection Control. (See editor’s note at end of article.)

Joint Commission changes under the environment of care area include EC.1.7, which calls for a plan describing how the organization will establish and maintain a utility systems management program to "reduce the potential for organization-acquired illnesses."

The plan should provide processes for managing pathogenic biological agents in cooling towers, hot water, and other aerosolizing water systems. In addition, ICPs now should be involved in ensuring appropriate air pressure for medical rooms, air exchange rates, and filtration efficiencies for ventilation systems serving areas specially designed to control air borne contaminants.

In essence, the Joint Commission changes require an effective working relationship with
the plant engineering program, said co-speaker Ona Baker Montgomery, RN, BSN, MSHA, CIC, infection control coordinator for the Department of Veterans Affairs Medical Center in Amarillo, TX.

According to Montgomery, the Joint Commis-sion has clarified that the intent of the new standard is "to engender communication between plant managers and infection control professionals, most likely to include review and approval of engineering policies and procedures related to infections, preventive maintenance and culturing guidelines to be used if there is a case of suspected or known nosocomial infections."

"This is a big change," Montgomery said. "Infection control programs may not have traditionally approved engineering policies on [heating/ventilation] or maintenance of the cooling towers. Yet those things are expected to be reflected in collaborative work now."

The key issue with water quality is controlling legionella species, she said. "Certainly if you are from a facility that has had problems with legionella in the past, you already have a plan for control, whether it has to do with hyperchlorination or hyperheating," she told teleconference attendees. "But if your facility has never had a problem before you probably don’t have a plan written down."

The written plan should clarify that ICPs do active surveillance for cases of legionella, including determining whether they are nosocomial. Clarify the steps that will be taken if legionella is found to be nosocomially acquired, she added. "If your steps include environmental culturing, then you might also want to state how you accomplish that. Because most [clinical] labs don’t do that themselves. They are going to have to send it out to a reference lab."

Regarding the emphasis on air quality, remember that the Joint Commission is "not just talking about your negative-pressure rooms for airborne isolation, which you have probably already addressed in your TB exposure control program," she said. Surveyors now are looking at other areas of negative pressure, for example, microbiology laboratories and some decontamination areas. Positive pressure and air exchanges also may be reviewed for operating rooms.

"One of the things that you might give consideration to is being careful to document in your infection control or oversight committee minutes, what is being done to monitor these various utility system management elements," Montgomery said. "You might even want to put it in the routine report that is done monthly. It shows good collaboration between plant engineering and infection control, and it goes back to the patient safety standards. Because if you have outbreaks . . . that goes directly to patient safety issues."

A less predictable process

Overall, the Joint Commission survey process has changed, including a new emphasis on "individual-centered evaluations," said Spath. "[That] is a technique used by the surveyors to evaluate multiple functions within your organization by looking at specific cases."

For example, when surveyors on a nursing unit pull the chart of a diabetic patient, they will be looking at all aspects of care. "They will essentially follow that patient through the process of patient care," she said. "If the patient had a nosocomial infection for example, they will be asking the nurse for information on infection control and perhaps how the ICP got involved in the case and implemented isolation or other issues that might be involved."

Anticipate that more complex cases will be pulled for review, Spath suggested. "You’re not likely to find a short, one-day stay chart being the one that gets pulled by the Joint Commission."

In addition, surveyors are placing more emphasis on interviews with staff, rather than relying on a walk-around briefing from the hospital-appointed compliance expert.

"In the past, as a quality management professional, I would trail behind the surveyor answering every single question they had," Spath said. "Well, that isn’t going to happen anymore. They are going to expect the staff to know the answers to questions. Of course that means for ICPs, you are going to have to make sure that your staff are educated on your policies on how to care for patients and help prevent infections."

Of course, questions will vary by hospital, and will likely be influenced by what the surveyor detects as the inspection unfolds.

"Really what they are most interested in is what they discover as they are reviewing cases in your facility," Spath added. "It tends to make the survey a lot less predictable."

[Editor’s note: To order an audiotape of "The New JCAHO Process: Is Your Infection Control Department Ready?" contact the AHC customer service department at (800) 688-2421.]