New JC Survey Citation Changes Starting

Everything a Joint Commission surveyor cites becomes a requirement for improvement (RFI) that must now be addressed in 60 days. This is because A and C elements of performance have been deleted and there are no longer direct and indirect elements of performance, explains Robert Campbell, PharmD, Senior Associate Director of The Joint Commission’s Standards Interpretation.

As part of the survey report an organization receives, all RFIs are presented within the SAFER matrix tool, which the Joint Commission released last year to help leaders prioritize survey citations according to risk for patients, visitors and staff.

Ultimately, “a survey is a risk assessment and this approach better organizes survey findings by level of potential patient impact to help organizations prioritize resources for response,” Campbell says.

How Leaders Are Now Expected to Respond

For higher risk RFIs, additional detail will be required in response, including leadership involvement regarding corrective action sustainment and preventive analysis. Campbell shares examples of this leadership engagement and oversight, which may include:

• ensuring the appropriate resources are available and used,
• being the champion for change management, and
• establishing intervals for communicating monitoring, reporting and oversight of monitoring.

“Change can only be sustained if there is staff and leadership engagement … leadership engagement should increase as risk identified on survey increases,” Campbell says.

What to Expect on Survey Day

Prepare your team members to identify and follow specific manufacturer instructions for use (IFU), Sylvia Garcia-Houchins, Infection Control Director at Joint Commission advises, noting that “multiple outbreaks and clusters have been linked to failure to follow IFUs.” When there are conflicts between manufacturer instructions, she says facilities are expected to resolve these conflicts.

Surveyors will focus on federal requirements to protect staff, such as use of personal protective equipment. They may question facilities regarding state specific requirements depending on the state.

Evidence based guidelines and national standards must also be well defined, deliberate, and detailed, Garcia-Houchins says. For example, a facility may choose to adopt AORN standards for operative and procedural settings and American Institute of Ultrasound In Medicine (AIUM) standards in areas performing ultrasound. In some instances, ultrasound may be used in operating and procedural settings and facilities should be clear when both apply and, if there is a difference, when one takes precedence over the other. Facilities should have a copies of the relevant guideline(s) available to staff who are responsible for implementation of these standards.

One important practice surveyors will be watching is instrument handling, both in procedural and sterile processing areas. Here are several specific practices surveyors will be looking for:

• Pre-cleaning of endoscopes at point of use is required.
• Wiping or flushing of surgical instruments during use if recommended by IFU.
• Implementation of a process or processes to minimize risk of bioburden drying on soiled instruments.
• Competency of staff to follow IFUs when performing cleaning, disinfection or sterilization.
• Appropriate physical facilities to perform reprocessing in accordance with IFUs.
• Availability, maintenance, and use of reprocessing supplies and equipment in accordance with IFUs.
• Use of controls (such as administrative, physical, biological and/or chemical) to monitor reprocessing.

Scoring Refinements

There have been refinements made to the scoring guidelines that will prioritize survey observation scoring based on risk of process failure, risk to the patient, and risk to staff. 

Instrument handling and processing is one key area where this scoring has changed. For example, where survey scoring was previously based on “visible bioburden and dried blood found on instruments,” it will now be based on “wiping/flushing of soiled instruments is not observed during a case in the operating room or procedure room and it is clinically appropriate” or “item for use on a patient is visibly soiled.”

A list comparing previous and current scoring for infection control and other standards relevant to perioperative practice can be found here. Additional specific examples of scoring refinements were published in a September 5, 2018 article in Joint Commission Online.

FREE RESOURCES FOR MEMBERS

Guideline Essentials: Ensure you and your team are survey-ready with access to online implementation tools for more than 20 AORN guidelines.

• Gap Analysis Tools: Tools to assess areas in which your facility may not be compliant with the guidelines.
• Policy & Procedure Templates: Ready-to-use customizable templates for developing your facility’s policies and procedures
• Competency Verification Tools: Ready-to-use customizable templates for verifying competency to meet facility requirements
• And more!