Hand Hygiene Compliance Now Mandatory in All Ambulatory Care Settings | Joint Commission
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Hand Hygiene Compliance Now Mandatory in All Ambulatory Care Settings

Feb 08, 2018 | 6364 Views

By Mary Brockway 

Director, Clinical Research 

Department of Standards and Survey Methods 

brockway_picA decade ago, The Joint Commission began requiring health care organizations to maintain a hand hygiene program. For the past several years, deemed ambulatory surgery center (ASC) surveyors have cited hand hygiene as an expectation of the Centers for Medicare and Medicaid Services (CMS). Starting this year, ambulatory care surveyors will issue a citation if they witness any ambulatory care organization employee failing to follow correct hand hygiene guidelines before providing direct patient care. 

Reality of Complying 

By now, we all know that hands are the major pathway for germ transmission in all health care settings.  

Ensuring clinician and staff hand hygiene before and after every patient contact reduces the risk of acquiring an infection in a health care setting. Unfortunately, the Centers for Disease Control and Prevention (CDC) estimates that—on average—healthcare providers follow hand hygiene guidelines less than half as often as they should.  

That doesn’t mean that staff are not taking the responsibility seriously. After all, healthcare providers may have to wash their hands or use alcohol-based hand sanitizers upwards of 100 times per shift, depending on their organization’s patient volume.      


Deficiency Risk 

Regardless of how many previous times in a day an ambulatory care provider may have followed their hand hygiene guidelines, if a surveyor notices an individual skip the hand hygiene step, it can result in a deficiency resulting in a Requirement for Improvement (RFI) under Infection Prevention and Control (IC) Standard IC.02.01.01, EP 2: “The [organization] uses standard precautions, including the use of personal protective equipment, to reduce the risk of infection.” 


Additionally, organizations must do their part to demonstrate compliance with the Centers for Disease Control and Prevention (CDC) and World Health Organization (WHO) hand hygiene guidelines. According to Dana Dunn, Joint Commission ambulatory care field director, “our surveyors will continue assessing the organization’s hand hygiene program compliance with National Patient Safety Goal NPSG.07.01.10, demonstrating they comply with CDC or WHO hand hygiene guidelines.” 

There’s an App for That

For many years, The Joint Commission Center for Transforming Healthcare has offered the Hand Hygiene Targeted Solutions Tool (TST)® for accredited organizations, providing the technology to measure performance and identify barriers to improving and sustaining hand hygiene compliance.  

Now, the TST® tool is available as an app from the Apple or Google Play Store to electronically track your organization’s hand hygiene compliance. With the ability to record hand hygiene observations on any smartphone or tablet, TST® Hand Hygiene users can now enter project data observations in real time.  

If you’re more comfortable with the tried-and-true paper form, that’s still an acceptable process. The method you use to improve hand hygiene compliance in your organization is your choice, but do make sure every employee is following your chosen hand hygiene policy. If you’d like to learn more about hand hygiene, the December 2017 issue of Perspectives offers a helpful summary on this important infection prevention topic.  

Mary Brockway is director of clinical research and standards at The Joint Commission. Prior to joining the enterprise, she was manager of clinical operations at Advocate Health Care in the greater Chicago area. 


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