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Sunday 10:48 CST, May 20, 2018


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Accreditation and Certification

December 20, 2017

Effective Jan. 1, 2018: Individual hand hygiene failures to be cited under IC, NPSG standards

TST-hand-hygiene-595-x-305Beginning Jan. 1, 2018, any observation by surveyors of individual failure to perform hand hygiene in the process of direct patient care will be cited as a deficiency resulting in a Requirement for Improvement (RFI) under the Infection Prevention and Control (IC) chapter for all accreditation programs. 

Standard IC.02.01.01, element of performance (EP) 2, states, “The [organization] uses standard precautions, including the use of personal protective equipment, to reduce the risk of infection.”

Hand hygiene is widely known to be the most important intervention for preventing health care-associated infections (HAIs). Surveyors also will continue surveying an organization’s hand hygiene program to National Patient Safety Goal (NPSG) 07.01.01. The Joint Commission introduced this NPSG in 2004. It requires health care organizations to: 

  • Implement a hand hygiene program.
  • Set goals for improving compliance with the program.
  • Monitor the success of those plans.
  • Improve the results through appropriate actions.

In general, surveyors issue an RFI to organizations for failure to implement and make progress in their hand hygiene improvement programs, according to NPSG.07.01.01. With the exception of the Home Care and Ambulatory Care Accreditation programs, observations of individual failure to perform hand hygiene were not cited as deficiencies if there was otherwise a progressive program of increased compliance. Because organizations have had since 2004 to implement successful hand hygiene programs, The Joint Commission has determined that there has been sufficient time for all organizations to train personnel who engage in direct patient care. While there are various causes for HAI, The Joint Commission has determined that failure to perform hand hygiene associated with direct care of patients should no longer be one of them.

The Joint Commission Center for Transforming Healthcare also launched the Hand Hygiene Targeted Solutions Tool®, which is free of charge to all accredited organizations.

Questions may be directed to the Standards Interpretation Group via the online question form.

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