Infection Prevention and Control chapter fully revised for hospitals, critical access hospitals

Effective July 1, 2024, a fully revised Infection Prevention and Control (IC) chapter, including new and revised requirements, has been approved for all Joint Commission-accredited critical access hospitals and hospitals. The goal of the IC chapter rewrite was to help organizations develop a strong framework for their IC programs, while aligning requirements more closely to law and regulation and the U.S. Centers for Medicare & Medicaid Services (CMS) Conditions of Participation (CoPs).

In keeping with the ongoing initiative to simplify standards content and structure, The Joint Commission eliminated requirements that do not add value to accreditation surveys so that organizations can focus on the structures that support IC quality and safety. The rewrite resulted in a 70% reduction of EPs in the chapter.

Revisions include:

• Removed elements of performance (EPs) related to waste management and responding to an influx of potentially infectious patients because they were redundant to existing Environment of Care (EC) and Emergency Management (EM) requirements.
• Added new Standard IC.07.01.01 with its two new EPs to enhance critical access hospitals’ and hospitals’ preparedness for high-consequence infectious diseases or special pathogens. These new requirements are based on scientific literature, government resources, and recommendations from The Joint Commission’s technical advisory panel on emerging infectious disease preparedness.

In addition, The Joint Commission created a new IC Assessment Tool that details the IC practices and structures needed to meet the IC requirements. The tool was developed using regulations, CMS survey procedures, the CMS Hospital Infection Control Worksheet, the US Centers for Disease Control and Prevention (CDC) Core IC Practices, and Category IA recommendations from CDC guidelines. The new tool is posted to the Joint Commission Connect^® extranet site (Go to “Survey Process” tab, under “Pre-Survey” menu, click on "Survey Activity Guide" and scroll down to "Additional Resources") for accredited critical access hospitals and hospitals; it will be added to the Critical Access Hospital and Hospital Organization Survey Activity Guides in spring 2024.

More information about the revisions is available in the project’s R3 Report. The new and revised IC requirements, as well as a reference guide showing where concepts from the old EPs have moved in the new EPs, is available on the Joint Commission’s website and will publish online in the spring 2024 E-dition^® update to the Comprehensive Accreditation Manual for Critical Access Hospitals (CAMCAH) and Comprehensive Accreditation Manual for Hospitals (CAMH). For those customers who purchase it, the CAMH 2024 spring update service will include these new and revised requirements.

For more information, contact the Department of Standards and Survey Methods using the Standards Online Submission Form.