By Sylvia Garcia-Houchins, RN, MBA, CIC, director of infection prevention and control
The Joint Commission announced they would cite one occurrence of failure to perform proper hand hygiene in health care facilities to remind organizations the importance of hand hygiene in a 2017 statement.
Two years later, The Joint Commission still stands behind this statement. Organizations are encouraged to remember that this is not intended as a punitive measure; rather, this policy is in the best interest of patients and health care workers alike as the risk of health care associated infections (HAIs) are decreased when hand hygiene is performed. When health care workers see someone forget to perform hand hygiene, the expectation is that they will speak up to protect the person, the patient and themselves. In similar fashion, when the Joint Commission surveyor is at an organization and they see a staff member not wash their hands, they have a responsibility to the patients and the organization to remind leadership and staff of the importance of hand hygiene. They do this by scoring failures to perform hand hygiene and surveying for compliance with hand hygiene standards.
The Joint Commission standards require that health care organizations to:
- implement a hand hygiene program based on regulations, Centers for Medicare & Medicaid Services (CMS) requirements (if deemed), manufacturer instructions and evidence-based guidelines (either Centers for Disease Control and Prevention or World Health Organization)
- identify opportunities to improve compliance with hand hygiene
- set goals to improve compliance based on identified priorities
- monitor compliance with the hand hygiene program and progress toward goals
- improve results through appropriate actions
Unfortunately, some organizations have misinterpreted these requirements to mean that they must perform surveillance in all hospital locations or be at 90-100% compliance with hand hygiene, or surveyors will find them out of compliance with Joint Commission standards.
This is not the case!
The Joint Commission expectation is that organizations use a robust process improvement model to identify issues related to hand hygiene and improve compliance in areas where some aspects of hand hygiene may be less than stellar. The goal is to improve patient and staff safety – not satisfy a surveyor.
Organizations need to identify and adopt effective ways to collect data about hand hygiene compliance to identify opportunities and monitor the impact of improvement efforts. There has been a lot of information published on methods to collect hand hygiene data and organizations are encouraged to explore and implement methods that will give them the most accurate and actionable data.
In some instances, this may mean that initial compliance is low – sometimes in the teens or twenties. But do not let that be the cause for not implementing a rigorous surveillance method- use the opportunity to improve!
Infection preventionists often ask if the organization’s surveillance system must monitor all “five moments” of required hand hygiene or all hospital locations. As a result, organizations may get stuck at the planning and data collection phases and not move on to the improvement phase.
The Joint Commission is not prescriptive on how or where surveillance is performed. For example, surveillance could be used to identify that staff are not performing hand hygiene in all, a few or any one of the following times that are required by CMS:
- before contact with the patient
- before performing an aseptic task (e.g., insertion of IV or urinary catheter)
- after contact with the patient
- after contact with blood, body fluids, or visibly contaminated surfaces
- after removing gloves
Or, surveillance could be used to identify direct care providers who are wearing artificial fingernails or nail extenders which CDC recommends (1A) not be worn by personnel having direct patient care in high risk areas such as intensive care units and operating rooms and WHO recommends (1A) not be used by direct patient care providers.
Organizations can tailor surveillance and improvements to the risks that are identified in their unique healthcare settings. However, it is key that the focus be in areas where there is a need for improvement. Collecting data that says you are at 90-100% compliance is great – it may be true that compliance is that high and after sustained improvement it is time to find another aspect of hand hygiene to improve or it may be that the method for data collection is flawed. Either way, thoughtful analysis is important. It may be time to change your surveillance methodology or your area of focus to improve the safety of your staff and patients.
Remember the goal is not to perform surveillance; the goal is to protect patients and health care workers.
For more information on hand hygiene and helpful tools, please visit The Joint Commission’s hand hygiene website.
Sylvia Garcia-Houchins is the Director, Infection Prevention and Control for The Joint Commission. Garcia has over 30 years of experience in infection control. Before coming to the Joint Commission, she served as the Director, Infection Control at University of Chicago Medicine and was also an intermittent consultant for Joint Commission Resources for 10 years. Ms. Garcia-Houchins has provided infection prevention and control consultation, assessment and education in a variety of health care settings including hospitals, health clinics, ambulatory surgery, and dialysis centers both domestically and internationally.