Infection Control Challenges: What They Reveal, How You Can Respond | Joint Commission
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Infection Control Challenges: What They Reveal, How You Can Respond

Jun 14, 2017 | 2748 Views

Lisa Waldowski By Lisa Waldowski, MS, APRN, CIC
Infection Control Specialist
Standards Interpretation Group
The Joint Commission

Leading the most recent list of the Top Ten Challenging Standards for accredited Ambulatory Health Care (AHC) customers over the last year is an infection control (IC) standard cited more than any other standard in 2016. 

The standard – IC.02.02.01, EP 2 – is: 

  • The organization reduces the risk of infections associated with medical equipment, devices, and supplies by performing a high-level disinfection and sterilization.

Spike in Related Potential Harm to Patients
Confusion surrounding this critical infection control and prevention standard has led in 2016 to 43% of our AHC organizations and 53% of our Office-Based Surgery (OBS) customers experiencing at least one non-compliant finding associated with IC.02.02.01, EP 2. Additionally, these findings – linked to lapses in high-level disinfection (HLD) and sterilization processes – are also associated with the highest-risk survey findings.

Careful review by The Joint Commission reveals that from 2013 through 2016, immediate threat to life (ITL) declarations directly related to improperly sterilized or HLD equipment increased significantly. 74 percent of all ITLs – across all accredited programs – were related to improperly sterilized or HLD equipment in 2016. This is a critical issue requiring a serious response.

Consequences of failing to manage these health care risks could result in adverse outcomes for ambulatory care organizations, including:

  • placing patients at risk for contamination
  • causing potential outbreaks
  • potential loss of Joint Commission accreditation
  • potential reversal of Centers for Medicare and Medicaid Services (CMS) certification status
  • negative publicity, lost business and a damaged reputation
  • litigation

The safety checklist for leaders provided in the recent Quick Safety #33 offers detailed ‘actions’ for ambulatory care organizations to take. Here’s a sampling:

Activity  Accountable Staff  Yes / No

Competency and training: Assure that staff who perform HLD and sterilization have been trained and are deemed competent to do so and those with supervisory oversight are competent to sign-off and monitor staff conducting HLD or sterilization.

What to ask: How often do you assess for staff competency? How are managers/supervisors deemed competent? Where are documented competencies kept?



Quality Monitoring: Assure that HLD and sterilization quality control requirements are rigidly followed and documented.

What to ask: Show me the documentation logs for HLD and/or sterilization. Are they complete? Are there gaps?

Frontline Staff and/or Managers/Supervisors














The significance of failing to address these issues cannot be understated. Breaches in equipment sterilization and HLD processes may result in outbreaks of HIV or hepatitis B. The transmission of bacterial infectious agents is also a real possibility, including multi-drug resistant organisms, E.coli, MRSA (methicillin resistant Staphylococcus aureaus) and Clostridium sordellii. Preventing the spread of these highly infectious agents is of critical importance.

What You Can Do

The Joint Commission offers several recommendations for improving your organization’s HLD and sterilization activities. Check out these suggestions from the June issue of Perspectives:

  • Follow current nationally recognized evidence-based guidelines specific to sterilization and HLD processes.
  • Verify that manufacturer’s instructions for use are readily available to staff and employed for all equipment, devices, and supplies requiring sterilization or HLD.
  • Create organizational policies and procedures for sterilization and HLD that are supported by manufacturers’ instructions for use and evidence-based guidelines.

And consider these key findings from non-compliant organizations (see more at Quick Safety #33):

  • Staff lack the knowledge or training required to properly sterilize or HLD equipment.
  • Lack of leadership oversight.
  • Sterilization or HLD of equipment becomes a low priority within the organization.
  • Processes for sterilization or HLD are not followed (i.e., staff take shortcuts).
  • The time frames for proper sterilization or HLD of equipment are not followed.
  • Facility design or space issues prevent proper sterilization or HLD of equipment (e.g., processing takes place in a small room that also is used for storage).

We strongly encourage you to take the time to review how your ambulatory care organization is addressing all of these critically important infection control and prevention issues.

For additional questions on this or any other accreditation-related issue, please contact your account executive at 630.792.3007.

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