Joint Commission pushes 90% flu goal
Joint Commission pushes 90% flu goal
Standard calls for yearly improvement
Beginning in July 2012, The Joint Commission will require hospitals to improve influenza rates annually and to work toward a national goal of 90% flu vaccination of health care workers.
However, the accrediting agency did not establish a mandate as a condition of accreditation. The Joint Commission said, "The changes to the standard were made in response to increasing attention in the United States on improving patient safety by having health care personnel vaccinated against influenza. Both government and professional organizations have emphasized the need to increase patient safety by decreasing patients' exposure to the influenza virus while receiving health care."
A similar standard also will apply to ambulatory care, behavioral health care, long-term care, home care and laboratory services. This is the revised standard:
Standard IC.02.04.01
Influenza Vaccination for Licensed Independent Practitioners and Staff
The hospital offers vaccination against influenza to licensed independent practitioners and staff.
Note: This standard is applicable to staff and licensed independent practitioners only when care, treatment, or services are provided on-site.
When care, treatment, or services are provided off-site, such as with telemedicine or telephone consultation, this standard is not applicable to off-site staff and licensed independent practitioners.
Elements of Performance
- 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; nonvaccine control and prevention measures; and the diagnosis, transmission, and impact of influenza. (See also HR.01.04.01, EP 4)
- The hospital provides influenza vaccination at sites and times accessible to licensed independent practitioners and staff.
- The hospital includes in its infection control plan the goal of improving influenza vaccination rates. (For more information, refer to Standard IC.01.04.01).
- The hospital sets incremental influenza vaccination goals, consistent with achieving the 90% rate established in the national influenza initiatives for 2020.
Note: The U.S. Department of Health and Human Services' Action Plan to Prevent Healthcare-Associated Infections is located at: http://www.hhs.gov/ash/initiatives/hai/tier2_flu.html. - The hospital has a written description of the methodology used to determine influenza vaccination rates. (See IC.02.04.01, EP 1)
Note: The National Quality Forum (NQF) Measure Submission and Evaluation Worksheet 5.0 provides recommendations for the numerator and denominator on the performance measure for NQF #0431.
The Joint Commission recommends that organizations use the Centers for Disease Control and Prevention (CDC) and the NQF proposed performance measure to calculate influenza vaccination rates for staff and licensed independent practitioners. The CDC/NQF measure, however, does not include all contracted staff. Therefore, The Joint Commission recommends that organizations also track influenza vaccination rates for all individuals providing care, treatment, and services through a contract, since contracted individuals also transmit influenza.
- The hospital evaluates the reasons given by staff and licensed independent practitioners for declining the influenza vaccination. This evaluation occurs at least annually.
- The hospital improves its vaccination rates according to its established goals at least annually. (For more information, refer to Standards PI.02.01.01 and PI.03.01.01)
- The hospital provides influenza vaccination rate data to key stakeholders which may include leaders, licensed independent practitioners, nursing staff, and other staff at least annually.
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