Infection control variables for Joint Commission accreditation audit compliance

Infection Control

Surgical site infections are a major issue for any hospital and the eradication of these events is the goal of hospitals and regulatory agencies. The Joint Commission completed a surveillance of the hospital and they gave specific advice regarding surgical site infection control and the results that they had gathered. This particular plan focuses on infection control because it a very critical area that can cause dire issues with patients and leave the hospital with both fiscal and reputational problems. To address the issues with infection control the Joint Commission guidelines state that

"Infection control includes the surveillance/identification, prevention and control of infections among patients/clients/residents/, employees, physicians, and other licensed independent practitioners, contract service workers, volunteers, students and visitors" (Joint Commission, 2010). This comprehensive view of infection control is an important consideration when developing a plan to ensure that all of the areas in the Joint Commission accreditation survey are complied with.

To ensure that the Joint Commission standards are met for this inspection, the following plan will contain the following are that are central to the infection control survey of the hospital. They identify four sub-processes that will be used as reporting areas. They are:

Surveillance/Identification

Prevention and Control

Reporting

Measuring

By developing a plan that includes all of these areas it is possible to meet the standards that the Joint Commission sets for hospitals.

The Plan

One of the main issues in recent years is that organisms are becoming more resistant to antibiotics and temperatures so they are able to continue to operate in conditions that would have previously killed them. This reality makes it imperative to identify the reasons for spread and the bacteria causing it. This plan will consist of the policy, responsibility, and the procedure needed to correct any issues.

Policy

Follow procedures set by appropriate state, local and federal agencies such as OSHA and other pertinent agencies.

Every employee will be required to have biannual in-service training regarding the importance of maintaining proper infection control. The training will consist of knowledge regarding the risks of infection, how to personally eradicate the possibility of infection, and guidelines regarding the need to secure an area that has become infected. Separate training will be given to surgeons, nurses and other staff responsible for conduct within the operating rooms. These individuals will be given additional training regarding their area since it is especially prone to infection.

Every infection that originates in the hospital will be monitored as to the specific type of treatment used and the success of the treatment.

Specific aspects of this control program are

1. Infections originating from surgical equipment

2. Drug resistant, especially multi-drug resistant infections

3. TB

4. Any communicable disease that is brought into the hospital.

5. The health trends of the hospital staff to determine if pathogens are more prevalent during specific times or if their incidence is increasing.

6. The exposure that staff receive to blood borne pathogens and other body fluid related infections.

There will be continuous collection of samples to detect specific pathogens.

The hospital will use a multidisciplinary approach that will include the efforts of staff from different areas of the hospital who have detailed knowledge of and interest in controlling infections.

Responsibilities

Every unit will understand exactly what about their particular job presents the most risk and be able to combat that immediately. This means knowing the signs of infection, where it is most likely to occur and how to prevent its incursion.

The nursing staff as a whole will be responsible for the policies that are important to their job and, when working in another area of the hospital, are responsible to check if any further procedures are required in that area. Nurses are also responsible to check the instruments in the operating room to make sure that they meet with infection control guidelines.

Surgeons are responsible to always keep the field clear and to examine patients for any obvious signs of infection prior to operating.

The hospital administration is responsible for support of all personnel who are responsible for preventing infection in the hospital.

Procedure

There is always need for improvement to any plan at times because infection is an issue that continues to grow. Therefore, monitoring of infection control procedures will be constant, and if anyone notices a procedure that would better fit a particular situation they are responsible to bring that to the attention of the staff who can affectively make the desired change.

All of these changes will be documented and forwarded to state agencies, the CDC (if warranted) and other agencies that have need of the information.

All data gathering within the area of control will be the responsibility of a designated infection control specialist who will forward the information. The lab will have designated personnel who can act in this function and will be trained to do so. Every shift will have an individual so designated so that immediate action can be taken if needed.

One particular issue that the Joint Commission noticed in their last inspection was the control of food and drink brought on the floors (Nightingale Community Hospital, 2010). All personnel will understand the need to properly store food and the possibility of infection if food brought from home is consumed on the floor. All floor refrigerators will be checked twice a week for food and beverages that are not labeled properly or that which has expired.

Trends will be searched for in the data collected and these will be examined to see if further controls need to be put in place at specific places.