Are organizations required to conduct surveillance on all surgical procedures, or is targeted surveillance acceptable ?

Any examples are for illustrative purposes only. 

No, there is no requirement that all surgical procedures be included in an organization’s surveillance for surgical site infections (SSI).  We expect organizations to follow a hierarchical approach when establishing infection surveillance. We would first expect organizations to follow applicable federal and state law and regulation, then if deemed or required by state regulation, to follow CMS requirements.  Some states have specified surgical procedures for which surveillance must be performed.  If mandated by your state, then the Joint Commission would expect your organization to be compliant to that requirement.

In the absence of federal/state mandates for specific surgical site infection surveillance requirements, organizations may choose to target SSI surveillance based on the results of a risk assessment (IC.02.05.01 EP 2). If an organization's risk assessment shows that risk is greatest for certain procedures or settings, the surveillance program may be targeted to focus resources on those high-risk procedures (IC.01.03.01) Organizations may wish to consider conducting periodic risk assessments to ensure that the scope of the targeted procedures included in surveillance activities remains current. Conducting a risk assessment is a helpful way of identifying risks associated with various procedures performed.   A proactive risk assessment examines a process in detail including sequencing of events, actual and potential risks, and failure or points of vulnerability and that prioritizes, through a logical process, areas for improvement based on the actual or potential impact (that is, criticality) of care, treatment, or services provided.

The introductory section of the Leadership (LD) chapter provides an example of a pro-active risk assessment model that an organization may use.  However, this specific approach is not mandated as there are other risk assessment tools available that may better meet the needs of the organization.   Other examples may include a root cause analysis, failure mode and effect analysis, plan/do/check/act process, etc., or combinations and variations.

The risk assessment should focus on all components of the surgical continuum, including – but not limited to - staff knowledge and competency, adoption of – and compliance with - evidence-based guidelines for reprocessing of instruments, policies and procedures, surgical attire, practitioner engagement, and patient education.  Compliance with any state-specific reporting requirements should also be evaluated.  From a quality and safety perspective, ensure that surgical procedures performed in all locations have been integrated into the organization-wide quality assessment and performance improvement (QAPI) program. 


Additional Resources: 
National Healthcare Safety Network (NHSN) 
Center for Disease Control and Prevention
Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals
The Joint Commission Center for Transforming Healthcare:  Video - Tackling Surgical Site Infections